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Sexual Harassment in Nursing: Ethical Considerations and Recommendations

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Seun Ross, DNP, MS, CRNP-F, NP-C, NEA-BC
Persis Naumann, B. Tech, MA
Darlene V. Hinds-Jackson, DNP, CRNP, FNP-BC, CNE
Liz Stokes, JD, MA, RN

Abstract

Sexual harassment has been increasingly identified as an issue of gender, role, power, society, and organizational demographics. Fear of reporting and the stigma attached to victims must be removed. Identifying and addressing sexual harassment in nursing is one of the most challenging tasks of nursing leadership and organization management. Promoting values and standards that shape behaviors, decisions, and relationships is key to instilling an ethics driven organizational culture and providing a safe environment. This article offers key definitions, and discusses ethical obligations to address sexual harassment in nursing. In addition, the authors offer recommendations for healthcare organizations and nurses, and general implications for practice. Establishing these measures, along with enforced zero-tolerance policies, modeling appropriate behaviors, and empowering nurses, is necessary to eradicate sexual harassment in the workplace.

Citation: Ross, S., Naumann, P., Hinds-Jackson, D.V., Stokes, L., (January 31, 2019) "Sexual Harassment in Nursing: Ethical Considerations and Recommendations" OJIN: The Online Journal of Issues in Nursing Vol. 24, No. 1, Manuscript 1.

DOI: 10.3912/OJIN.Vol24No01Man01

Key Words: Sexual harassment, nursing, workplace violence, ethics, corporate social responsibility, organizational culture, work environment, human rights, nurse abuse, zero tolerance policy, reporting

Sexual harassment is a global, pervasive, social phenomenon that is widespread across industries and occupations Sexual harassment is a global, pervasive, social phenomenon that is widespread across industries and occupations (Page, Pina, & Ginaer-Sorolla, 2016). Sexual harassment is documented in blogs, news, academic papers, and even social gatherings. Instances occur every day in settings at every level across the globe – business, education, hospitality, military, entertainment, medicine, government, and religious communities. This global concern has drawn international attention from the United Nations (UN), the European Union, International Labor Organization, and the International Confederation of Free Trade Unions over the last few decades (McDonald, 2012; Wong, 2010). Prior to the 1970s, sexual harassment had not been characterized as a social issue. Recent events have reignited and highlighted sexual harassment and sexual assault as abhorrent problems, often endured in workplace environments.

As a result of radical, feminist, grassroots movements, sexual harassment has become recognized as a widespread socio-legal issue, which especially affects women in a range of settings (Feder, 2010). The #MeToo movement was United States-based (U.S.) and took shape in 2006. Tarana Burke established the movement with the aim to assist women and girls, particularly women and girls of color, who survived sexual violence (Ohlheiser, 2017). The reach of the #MeToo movement spurred the creation of #TimesUp. This later movement was created by female members of the entertainment industry, starting with an impassioned pledge of support to working-class women. These groundbreaking anti-sexual assault and women’s empowerment movements upended the public conversation about these issues around the world. Thus they have elevated the global consciousness surrounding the obstacles women encounter in both their personal and professional daily lives.

Prior to the 1970s, sexual harassment had not been characterized as a social issue. The American Nurses Association (ANA) issued a position statement on sexual harassment (ANA, 1993), which called for the elimination of sexual harassment for nurses in all work settings. ANA continues to urge healthcare institutions to educate workers in ways to prevent sexual harassment and calls on hospitals to suspend staff who sexually harass employees. In 2017, ANA initiated #EndNurseAbuse, a social movement developed to raise awareness of violence against nurses, including sexual harassment, and to alert consumers and the public to pledge with nurses that these actions will not be tolerated (ANA, 2017). The culture shift has been palpable for the first time, the world has been put on notice that these movements are not to be ignored.

Identifying and addressing sexual harassment in nursing is one of the most challenging tasks of nursing leadership and organization management. Identifying and addressing sexual harassment in nursing is one of the most challenging tasks of nursing leadership and organization management. Promoting values and standards that shape behaviors, decisions, and relationships is key to instilling an ethics driven organizational culture and providing a safe environment. This article explores sexual harassment in the specific content of nursing, offers key definitions, and discusses ethical obligations to address sexual harassment in nursing. In addition, the authors offer recommendations for healthcare organizations and registered nurses, and general implications for practice. Establishing these measures, along with enforced zero-tolerance policies, modeling appropriate behaviors, and empowering nurses, is necessary to eradicate sexual harassment in the workplace.

Sexual Harassment in Nursing

A great deal of the literature related to sexual harassment in nursing is dated and this represents an opportunity for generation of new knowledge. However, sexual harassment in nursing has been an issue even prior to the term being defined (Bronner, Peretz, & Ehrenfeld, 2003). It has been a major problem in healthcare (Fiedler & Hamby, 2000) and particularly ubiquitous in nursing (Gardner & Johnson, 2001). A research study found 60% of female nurses and 34% of male nurses reported being victims of sexual harassment (Cogin & Fish, 2009)

The characterization of the ‘naughty nurse’ as either a social or costumed character alludes that nurses are sexual objects. The characterization of the ‘naughty nurse’ as either a social or costumed character alludes that nurses are sexual objects. Sexual harassment in nursing may occur from patients, patient family/friends, peers, or supervisors. It includes offensive jokes, showing of sexual body parts, touching body parts of nurses, and showing of sexual materials (Celik & Celik, 2007). There are many unreported incidents in which nurses have experienced rape, offers for sexual involvement, and other types of harassment at the workplace (Jackson &Ashley, 2005). Findings of various studies on sexual violence in healthcare settings reveal that female nurses are more prone to sexual violence because their gentleness, caring attitude, and compassionate nature is wrongly perceived by some as sexual signals (Celik & Celik, 2007; Kamchuchat, Chongsuvivatwong, Oncheunjit, Yip, & Sangthong, 2008; Randle, 2003).

Behavior does not constitute sexual harassment if it is welcome. It is important to have and understand a concrete definition of sexual harassment to ensure operation from the same perspective. While some behavior is so blatantly offensive that it is clearly sexual harassment, much behavior falls into a gray area. Behavior does not constitute sexual harassment if it is welcome. Supervisors can date employees, and co-workers can laugh at dirty jokes, and hug each other; if none of them object, it is not sexual harassment. If, however, someone objects or is subjected passively to this unwanted behavior, it is sexual harassment.

Key Definitions

Workplace violence consists of physically and psychologically damaging actions that occur in the workplace or while on duty (National Institute for Occupational Safety and Health [NIOSH], 2002). NIOSH classifies workplace violence into four basic types:

  1. Type I involves “criminal intent.” In this type of workplace violence, “individuals with criminal intent have no relationship to the business or its employees.”
  2. Type II involves a customer, client, or patient. In this type, an “individual has a relationship with the business and becomes violent while receiving services.”
  3. Type III violence involves a “worker-on-worker” relationship and includes “employees who attack or threaten another employee.”
  4. Type IV violence involves personal relationships. It includes “individuals who have interpersonal relationships with the intended target but no relationship to the business” (Iowa Prevention Research Center, 2001; NIOSH, 2006, 2013).

Research and anecdotal evidence suggest that many employees do not know what constitutes sexual harassment. The Equal Employment Opportunity Commission (EEOC) defines sexual harassment by the following:

Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitute sexual harassment when (1) submission to such conduct is made either explicitly or implicitly a term or condition of an individual’s employment, (2) submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting such individual, or (3) such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance, otherwise adversely affects an individual’s employment opportunities, or creating an intimidating, hostile, or offensive working environment (EEOC, 1990 paragraph 3114).

The EEOC describes two types of sexual harassment, quid pro quo and hostile work environment (EEOC, 2017). Each identifies different behaviors and liabilities; and behaviors in both situations must be unwelcome by the employee. These are defined as:

Quid Pro Quo. This means “something in exchange for something else,” and describes behavior in which a supervisor or other person of authority demands sexual favors from an employee in return for his or her job. Additionally, if the work environment becomes so intolerable due to sexual harassment that the person being harassed feels compelled to resign, constructive discharge may apply. This establishes a claim of quid pro quo because the employee was forced to lose employment because of sexual harassment.

Hostile work environment. Sexual harassment claims of hostile work environment involve such things as inappropriate posters, and sexual innuendos and jokes by supervisors, coworkers, and third parties (e.g., customers, patients, vendors). It is important to note that the harassment does not have to be directed at the individual making the complaint.

Harassment is prohibited even if it leads solely to non-economic injuries. If an individual observes sexual material or behavior or hears statements of a sexual nature that offend him or her and interfere with the ability of that person to do his or her job, then that person is the victim of sexual harassment. Employees have the right to be free from behavior that either unreasonably interferes with their work performance or creates a hostile work environment. Harassment is prohibited even if it leads solely to non-economic injuries.

The literature has characterized sexual harassment as a form of violence or aggression (O’Leary-Kelly, Paetzold, & Griffin, 2000; Johnson, 2016). Some studies have asserted that the frequency of verbal sexual harassment is much higher than that of physical sexual harassment (Arnetz, Arnetz, & Petterson, 1996; Anderson & Parrish, 2003; Camerino, Estryn-Behar, Conway, van Der Heijden, & Hasselhorn., 2008; Hegney, Plank, & Parker, 2003; Pai & Lee, 2011; Roche, Diers, Duffield, & Catling-Paull, 2010). A recent study conducted in public healthcare settings identified that 1 in 4, or 25%, of nurses worldwide had experienced verbal sexual harassment (Spector, Zhou, & Che, 2014). Previously, Shaikh (2000) reported that 16.9% of nurses had experienced physical sexual harassment from male physicians, male patients, and male co-workers (Shaikh, 2000).

Similarly, the findings of a study about the types of sexual harassment concluded that the prevalence of verbal sexual harassment among nurses was 55.7%, whereas physical sexual harassment was 39.1% (Chuang & Lin, 2006). The study on sexual harassment of nurses by Bronner et al., (2003), identified that, overall, 91% of nurses reported experiencing various kinds of sexual harassment in the workplace. Furthermore, 78.8% of nurses encountered teasing sexual remarks from patients and their relatives; 55.2% of nurses were asked by patients to initiate a romantic relationship; 48.5% of nurses experienced sexual jokes from patients; 45.8% of nurses experienced nonsexual touches; and 20.8% of nurses experienced sexual touches during the performance of nursing tasks in healthcare settings (Bronner et al., 2003).

Some studies have asserted that the frequency of verbal sexual harassment is much higher than that of physical sexual harassment The results of a recent study published by the Center for American Progress highlighted the pervasiveness of EEOC claims across the U.S. workforce and showed that healthcare industries rank 4th on the EEOC list of industries with the most reported sexual harassment claims (Center for American Progress, 2017; Frye, 2017, Nov 20). The healthcare industry accounted for 11.48% of the claims, in large part because it includes various employee types, such as nurses, medical assistants, childcare assistants, and Organizations that employ nurses, as well as the nursing profession itself, have an ethical obligation to address sexual harassment. home health aides; these positions are predominantly occupied by women and particularly people of color (Frye, 2017, Nov 20).

Empirical research on sexual harassment has been growing immensely all over the world and identifying sexual harassment in a variety of ways. This is leading to a discourse on feminism and equality in the workplace, and even social movements that translate to laws and practices in cultural, legal, and political contexts (Feder, 2010).

Ethical Obligations to Address Sexual Harassment in Nursing

Organizations that employ nurses, as well as the nursing profession itself, have an ethical obligation to address sexual harassment. Organizations that employ nurses, as well as the nursing profession itself, have an ethical obligation to address sexual harassment. The Code of Ethics for Nurses with Interpretive Statements obligates nurses to create “an ethical environment and culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect” (ANA, 2015, p. 4). It is morally unacceptable for nurses to disregard the effects of individual actions on others, including bullying, harassment, intimidation, manipulation, threats, or violence (ANA, 2015).

Sexual harassment negatively affects the physical health and psychological wellbeing of nurses and other healthcare professionals (International Council of Nurses [ICN], 2017). These effects can extend outside of the workplace into a nurse’s personal and social life (ICN, 2017). The ICN, which is the global voice of nursing, condemns workplace violence, including sexual harassment against nurses, because it puts nurse and patient safety at risk (ICN, 2017). ICN further supports the ethical obligations for nurses and organizations to develop system-wide approaches to address sexual harassment in order to avoid violations of human rights, freedom from harm, and safe work environments free from sexual harassment (ICN, 2017).

Analysis of ethical issues in sexual harassment in nursing has not received sufficient attention... Analysis of ethical issues in sexual harassment in nursing has not received sufficient attention, despite the understanding that sexual harassment as an ethical issue is important to reduce its frequency (O’Leary-Kelly, Bowes-Sperry (2001). It is well established that an issue transforms into an ethical issue if it has specific relevance to morality, values, and what is right or wrong. Sexual harassment is clearly an ethical issue as it involves a moral component of what is right and wrong. “When an individual is faced with a free choice between harmful (e.g., sexually harassing) or nonharmful actions, a moral issue exists; and the individual chooses the harmful action (e.g., sexual harassment), an unethical decision has been made” (O’Leary-Kelly & Bowes-Sperry, 2001, p. 75).

Sexual harassment in any profession violates universal fundamental ethical principles, including human rights and dignity; respect for human vulnerability; and personal integrity (O’Leary-Kelly, Bowes-Sperry, 2001). The following ethical analysis will evaluate not only the individual perpetrator of sexual harassment, but also the ethical obligations of peers and members of the healthcare team to intervene when they see it

Vulnerability and Human Rights
Inequalities, discriminatory practices, and significant power imbalances inherent in the root of sexual harassment inhibit the ability of nurses to speak out against harassers. According to the UN, human rights are “rights inherent to all human beings, regardless of race, sex, nationality, ethnicity, language, religion, or any other status. Human rights include the right to life and liberty, freedom from slavery and torture, freedom of opinion and expression, the right to work and education, and many more. Everyone is entitled to these rights, without discrimination.” (United Nations, n.d., para. 1). Inequalities, discriminatory practices, and significant power imbalances inherent in the root of sexual harassment inhibit the ability of nurses to speak out against harassers. Sexual harassment reflects a hostile environment and can lead to favoritism or discrimination of others. Harassment can go unreported due to a nurse’s personal or professional conflict and moral distress associated with reporting, including fear of retaliation, termination, disclosure of sexual history, and public shaming.

To be vulnerable is to be easily hurt, influenced, or attacked (ten Have, 2016). Therefore, it is vital to examine the notion of vulnerability in this context. Vulnerability can be applied to individuals, groups, and communities; related to physical, psychological, social, economic, and environmental conditions; or caused by internal or external conditions (ten Have, 2016). Furthermore, identifying vulnerability within sexual harassment is important because those affected may be at risk of harm through neglect, abuse, discrimination, exclusion, and oppression.

Therefore, when there is a threat of sexual harassment due to inequalities, discriminatory practices, and significant power imbalances in nursing, nurses are susceptible to sexual harassment and unable to protect their own interests, dignity, integrity, or rights. To overcome this threat, nurses may learn to adapt or make adjustments, such as relocation to a different unit or organization. This does not necessarily indicate a lack of autonomy but external conditions, such as a hostile environment that limits autonomy, thereby making nurses vulnerable to sexual harassment. Benefiting from individuals, by taking advantage of their vulnerability, is intuitively considered morally wrong. For this reason, vulnerable individuals require protection through effective implementable policies.

Nurses are entitled to workplaces that are safe and free of sexual harassment. Nurses are entitled to workplaces that are safe and free of sexual harassment. The human right to just power relations includes freedom and entitlement. Freedom includes the right to just and favorable conditions of work (UN General Assembly, 1948). Entitlement includes the right to a work environment that gives everyone an equal opportunity to enjoy the highest attainable level of the work environment, and economic, social, and psychological satisfaction (UN General Assembly, 1948) and the right to a system of protection that promotes ethical behavior, performance, and work environments.

Ethical Implications in Responding to Sexual Harassment
Sexual harassment in nursing, when identified, is often addressed in a superficial manner and from a legal standpoint, which has very little influence on day-to-day operations. While ethical issues such as sexual harassment are encountered by healthcare professionals on a regular basis, it is critical to recognize these ethical challenges. It is also vital to respond to them properly to make better ethical decisions. Sexual harassment in nursing, when identified, is often addressed in a superficial manner and from a legal standpoint, which has very little influence on day-to-day operations. For example, a perpetrator might be disciplined, but the victim might also face retaliation. At best, the Organizations adversely affected by the ethical issue of sexual harassment in the workplace pay a high price. The perpetrator might be removed from practice, but that may not change the ethical climate of a work environment.

When healthcare professionals in the organization, particularly the leaders, recognize the moral dimension of sexual harassment and identify it as an ethical issue, sexual harassment can be addressed from an ethical perspective. Incidents of sexual harassment in the workplace elucidate value-related issues in the broadest sense; and require organizational culture practices and policies to be in place (Johnson, 2016). Essential to this aim are well-developed reporting structures for sexual harassment and the implementation of evidence-based recommendations; proper education and training; and consistent enforcement (Somani, Karmaliani, McFarlane, Asad, & Hirani, 2015).

Organizations adversely affected by the ethical issue of sexual harassment in the workplace pay a high price. Organizations adversely affected by the ethical issue of sexual harassment in the workplace pay a high price. This can be in the form of damaged reputations; a decline in financial performance including revenues, earnings, donations, and stock prices; and civil lawsuits, criminal charges, and legal costs. It can also lead to reduced morale or motivation of employees; lower job satisfaction, commitment, and productivity; and employment withdrawal (Johnson, 2016). Therefore, to prevent these negative outcomes, it is imperative to improve the organizational management of sexual harassment.

Such an improvement would include instilling an organizational culture that is ethics-driven by promoting values and standards that shape behaviors, decisions, and relationships. One way to achieve this is through Corporate Social Responsibility (CSR), which enables organizations to take the ethical responsibilities toward its employees to promote moral behavior, acknowledge ethical performance, and establish an environment that fosters working together respectfully, ethically, efficiently, and addresses sexual harassment directly and transparently.

Corporate Social Responsibility
CSR is best described as the efforts of an organization to make society better; this includes the stakeholders of the organization, and particularly the employees (Johnson, 2016). Economists offer a strong argument that equates CSR with philanthropy, and CSR activities are usually employed by firms solely for public relation purposes. However, CSR activities should ideally include more engagement to build CSR toward stakeholders (e.g., employees) into the organizational DNA.

Nurses are often the largest workforce in a healthcare setting and, as such, hold a large stakeholder interest in organizational operations to ensure an environment free of sexual harassment. Although an organizational zero-tolerance policy may be in place, it may not be adequately enforced. From an ethical perspective, nurses have intrinsic value and their interests are valid and worthy of respect. This philosophy, therefore, requires consistent enforcement of policies intended to prevent and correctly address sexual harassment in the workplace.

Recommendations for Healthcare Organizations

Employers are required to take reasonable care to prevent sexual harassment... In an effort to instill and enforce an organizational culture that is safe and supportive of nurses, steps towards CSR must be initiated. Nurses must be aware of their rights, responsibilities, and duties should a violation occur. Employers are required to take reasonable care to prevent sexual harassment and to promptly correct sexual harassment once it occurs. An action plan inclusive of established policies, employee training, and reference materials should be implemented. Prevention is the first, last, and primary line of defense against sexual harassment. EEOC guidelines encourage employers to:

…take all steps necessary to prevent sexual harassment from occurring, such as affirmatively raising the subject, expressing strong disapproval, developing appropriate sanctions, informing employees of their right to raise the issue of harassment under Title VII, and developing methods to sensitize all concerned (EEOC, 2017, 1604.11f).

The Joint Commission has established a standard focused on a culture of safety and Quality (see Table 1).

Table 1. Joint Commission Standard LD.03.01.01

Joint Commission Standard LD.03.01.01 Leaders create and maintain a culture of safety and quality throughout the (organization).

A4. Leaders develop a code of conduct that defines acceptable behavior and behaviors that undermine a culture of safety.

A5. Leaders create and implement a process for managing behaviors that undermine a culture of safety.

(Applicable to ambulatory care, critical access hospital, home care, hospital, laboratory, long-term care, Medicare-Medicaid, certification-based long-term care, and office-based surgery programs and behavioral healthcare programs.)

Establish Policies
Employers should give each employee a copy of an easily understood policy and compliance procedure... EEOC guidelines stress the need for employers to establish, disseminate, and enforce anti-harassment policies and compliance procedures. Employers should give each employee a copy of an easily understood policy and compliance procedure, and redistribute it periodically (Gardner & Lewis, 2000). Employee handbooks should also include this policy. Employees should sign a statement acknowledging that they have read and understood the policy, and employers should review the policy annually with them to ensure continued understanding. Signed by the Chief Executive Officer, the policy should have the following key elements:

  • Zero-Tolerance. A clearly written, comprehensive statement of the employer’s zero tolerance of sexual harassment by anyone in the workplace is essential. It should clearly define sexual harassment, describing examples of acceptable and unacceptable behavior.
  • Protection. Assurances that employees who make harassment complaints and witnesses who provide information will receive protection from retaliation are important. A conspiracy of silence protects the harasser. Organizations must eliminate such codes of silence so that employees and witnesses will not fear reporting harassment. If the target remains silent, the harasser remains free to continue harassing behavior toward the target and others (Davidhizar, Erdel & Dowd, 1998).
  • Neutral Reporting Process. An easy to use, neutral process will encourage aggrieved employees to complain and provides several avenues to do so. For example, employers need to identify at least two neutral individuals to whom employees may complain. Employees should be assured that employers will promptly investigate all complaints.
  • Confidentiality. Assurances that the employer protects confidentiality to the extent possible are necessary; sharing of information should occur only with those who need to know. The greater the degree of confidentiality, the more likely targets will feel protected and comfortable about filing complaints and witnesses will be forthcoming with relevant information.
  • Impartiality. A complaint procedure should provide for prompt, thorough, and impartial investigations by disinterested parties. Healthcare organizations need to provide a means for handling same-sex harassment complaints.
  • Follow-up. First, there must be in an assurance that if harassment is found, the employer will take immediate and appropriate corrective action, up to and including termination. To prevent a recurrence, employers should then periodically review behavior of harassers once corrective actions have been taken to be sure those actions are working.

Offer Training
Employers need to train all employees repeatedly about their rights and responsibilities. In a study of staff trainers and human resources directors, 86% of respondents agreed that education and training had to be combined with appropriate policies as part of organizational efforts to eliminate sexual harassment (Gardner & Johnson, 2001). Training should be interactive to sensitize all staff; trainers should assess the effectiveness of the training effort to ensure trainees understand the material; and organizations should mandate at least one anti-harassment training session per year for every employee, regardless of job level. Training is also essential for employees in management as they hold higher responsibility and represent the company. It is who will field reports and implement consequences.

Employers should give each employee a copy of an easily understood policy and compliance procedure. The inclusion of practical examples of the various types of harassment (see Table 2), can increase the awareness about the range of behaviors that can be categorized as harassment. Providing employees with tangible references (e.g., pocket cards) with these examples may increase the identification and reporting of ambiguous and covert behavior. Whatever the nature of the training effort, organizational leaders should impress upon all employees the economic consequences of sexual harassment, including, but not limited to, adverse effects on productivity, corporate reputation, and job turnover, as well as the possibility of individual liability (Palow, 2000).

Table 2. Types of Sexual Harassment

Type

Behaviors

Verbal (spoken or written)

  • Offensive teasing, joking, questioning
  • Suggestive remarks or sounds
  • Terms of endearment (e.g., honey, sweetie, baby)
  • Requests for sexual favors
  • Whistling, catcalls
  • Inappropriate emails, letters, memos, telephone calls
  • Comments about appearance, clothing
  • Threats
  • Spreading rumors about a person’s personal or sexual life

Non-verbal

  • Sexual gestures (e.g., licking, making hand signals, eating in a provocative manner)
  • Winking
  • Leering/Looking inappropriately at a person’s body parts
  • Blocking one’s path/following a person
  • Giving personal gifts

Visual

  • Sexual exposure, including flashing or mooning
  • Offensive pictures, pornography, posters, or pin-ups
  • Offensive screensavers
  • Emails with offensive graphics (e.g., pictures, cartoons)

Physical

  • Touching, raping, brushing against the body, patting, stroking, hugging, kissing, fondling, massaging neck or shoulders

Psychological

  • Repeated undesired social invitations, proposals or contact resulting in anxiety and stress

(Lockwood, 2017)

Set an Example
Those in positions of hierarchical leadership need to set the behavioral example for everyone in the organization. The importance of setting the proper example of appropriate behavior cannot be overemphasized. Those in positions of hierarchical leadership need to set the behavioral example for everyone in the organization. These individuals occupy positions of power, and multiple studies have demonstrated that harassers are usually in powerful positions (Pierce & Aguinis, 1997; Cortina & Berdahl, 2008; Williams, 2018). By virtue of the leadership role, failure to carry out these responsibilities may carry significant financial implications if a court rules that sexual harassment has occurred.

Recommendations for Nurses

The onus is on the employee being harassed to always notify the employer... It is important to remember that the employer cannot be held responsible for behavior of which the employer is not aware. The onus is on the employee being harassed to always notify the employer (unless there is a reason to fear for personal safety). If the employer takes the appropriate action (e.g., reprimanding the harasser), the employer has acted with reasonable care. If the person continues to harass, the victim must report every incident of additional harassment. If the victim fails to do this, the employer may not be held accountable.

Nurses may choose to go through the employer’s complaint process or file a charge with their state’s fair employment agency or Federal EEOC. Nurses may also file a civil suit seeking damages. Under federal and most state laws, employees must file a complaint within 180 days of an act of sexual harassment (Lockwood, 2017).

Employees have a right to review their personnel files and to see any written evaluations. Before filing a complaint, nurses should ask to see their files and, if possible, make copies of the content. Some employers have retaliated against those complaining by filing negative evaluations or altering records (Lockwood, 2017). Table 3 provides information about various elements of the complaint process.

Table 3. Elements of the Complaint Process

Action

Rationale and Examples

Say “NO”

Consensual behavior is not sexual harassment, so the nurse must be very clear about saying “NO.”

  • If asked for a date, statements such as “I already have plans” or “I have a girlfriend,” or “I don’t like workplace romances,” is not the same as saying, “NO, I don’t want to go on a date with you.”
  • Laughing uncomfortably at a dirty joke is not the same as saying, “I don’t want to hear dirty jokes. They make me uncomfortable.”
  • Ignoring pornographic pictures is not the same as saying, “I find those pictures offensive and would like them removed.”

NOTE: If a patient sexually harasses a healthcare worker, the employee should deal with the matter directly by clearly stating, “Your behavior is inappropriate and unacceptable.”

Document

The nurse should document every incident of sexual harassment, including the date, time, description, and witnesses.

  • If a fellow employee witnesses the incident and does not want to “be involved,” that does not alter the fact that the person witnessed the interaction. They should still be listed as a witness.
  • Documentation should NOT be done on an employer-owned computer or through email(s) over an employer network
  • Documentation may contain photos of offensive material or copies of offensive letters or other forms of communication.
The employer should create a written record that contains copies of all documents. The employee should document the results of filing the complaint, including any actions the employer has taken to resolve the issue and the responses of those who had engaged in harassment. All letters, emails, and summaries of telephone conversations or meetings should be included. Should legal action be necessary, a careful written record may be critically important.

Report

Follow the employer's sexual harassment policies and procedures. The nurse should make a formal complaint to the appropriate supervisor in writing, outlining exactly what has occurred and providing evidence or supporting statements of witnesses as appropriate, in detail avoiding generic language and euphemisms. Subsequently, the employee should follow the same procedure if further harassment occurs.

Seek Support

The employee should seek support through friends, family, co-workers, and an Employee Assistance Program (EAP) if available. In some cases, the employee may benefit from assertiveness training or counseling. Those who seek professional counseling to deal with harassment should not sign a release of medical records prior to a discussion with an attorney.

(Lockwood, 2017)

Implications for Nursing Practice

Multiple studies have provided snapshots of violence exposure rates in nursing. The high rate of physical violence is well recognized and has been the focus of workplace interventions in many organizations. What is perhaps less acknowledged are the high rates of other types of violence, such as sexual harassment. However, research has yet to determine if the low rates of reported sexual harassment are due to under-reporting (Spector et al. 2014). Under-reporting is a major barrier to eradicating this phenomenon from nursing. Due to the sensitive nature of the topic, nurses have felt uncomfortable sharing the incidents they have encountered.

...research has yet to determine if the low rates of reported sexual harassment are due to under-reporting. This knowledge suggests that violence prevention programs need to be comprehensive, and deal with patients; their families and friends; and all staff members. Only by addressing all types of violence can the workplace become a safer environment. Table 4 offers recommendations to address sexual harassment from patients.

Table 4. Sexual Harassment by Patients

The personal nature of nursing may make you a target of inappropriate behavior from patients.

When the patient is the harasser:

  • Step away and tell the patient that such behavior or language is unacceptable.
  • Explain you will not be able to continue their treatment/procedure unless the behavior changes.
  • Be clear in your expectation of appropriate behavior.
  • Discuss the incident with your professional colleagues and your supervisor.
  • If the behavior continues, follow your organizational policies. Such policies may include changing the patient assignment; having hospital security converse with the patient; or discharging the patient from the hospital.
  • Develop a healthcare organization specific handout or flyer with information given to each patient on admission that specifically outlines expectations of patient behavior regarding inappropriate conduct (e.g. sexual harassment; harassment of other protected classes; disrespectful, rude, or bullying behavior).

(Lockwood, 2017)

Conclusion

Preventing sexual harassment in nursing requires intentional and specific action. Our review of the literature revealed a very limited, and predominantly dated, amount of sexual harassment research in nursing. Consequently, limited work has addressed the issue (Quick & McFayden, 2017). As a result, most organizations lack strategies to identify and manage this sensitive problem in the workplace. Preventing sexual harassment in nursing requires intentional and specific action. Healthcare organizations have an ethical imperative to safeguard their nurses and ethos.

Recognizing sexual harassment as an ethical issue and addressing sexual harassment through CSR and a human rights approach can be instrumental in combating sexual harassment in the workplace for nurses. The goal of the human rights approach should be that all policies, strategies, and programs related to sexual harassment are designed with the objective to protect and promote the right to non-discrimination, equality, and just power relations.

Protection from sexual harassment can be defined as a right and not a need. Protection from sexual harassment can be defined as a right and not a need. Sexual harassment requires a new form of communication, one which pays more attention to this concern as an organizational, rather than individual, ethical issue. As such, the answer necessitates organizational governance, culture, and policies that permeate the organization and appropriately shape individual ethical behavior.

Authors

Seun Ross, DNP, MS, CRNP-F, NP-C, NEA-BC
Email: Seun.ross@ana.org

Dr. Ross is the Director of Nursing Practice & Work Environment at the American Nurses Association (ANA). Dr. Ross is a published author, and lecturer on many topics within her research interests, which include evidence based practice, workforce management, RN work environment, competency and developing/mentoring the novice RN. She is currently the President of IMBUE foundation, Board member for MD CASA, a member of the Academy of Healthcare Executives and holds certifications as a family nurse practitioner and Nurse Executive-Advanced.

Persis Naumann, B. Tech, MA
Email: persisnaumann@gmail.com

Persis Naumann has a Bachelor of Technology in Biomedical Engineering; a Master of Arts in Healthcare Ethics; and is currently pursuing a Ph.D. in Healthcare Ethics at Duquesne University, Pittsburgh. Persis has extensive experience in a variety of fields including direct clinical experience, academic preparation, marketing, social work, and leadership. With her passion for healthcare ethics and expertise in global bioethics, Persis is continually working to contribute to her field, particularly at the intersections of class, culture, and gender.

Darlene V. Hinds-Jackson, DNP, CRNP, FNP-BC, CNE
Email: dhinds@coppin.edu

Dr. Hinds-Jackson is a tenured Assistant Professor FNP/DNP Clinical Coordinator Coppin State University Helene Fuld School of Nursing. She is a certified nurse educator and published author. She has been a registered nurse for 14 years and a registered family nurse practitioner for 10 years. Well-known within the Greater Baltimore area, she is also a member of the St. Agnes Hospital Community Council. Dr. Hinds-Jackson was awarded both Bachelor of Science-Nursing and Masters of Science-Nursing degrees from Coppin State University. She received a doctoral degree from West Virginia University.

Liz Stokes, JD, MA, RN
Email: liz.stokes@ana.org

Dr. Stokes is the Director of the American Nurses Association Center for Ethics and Human Rights and demonstrates expertise in writing public policy on ethical issues including assisted death, intellectual disabilities, and women's reproductive health. Liz's sphere of influence as a nurse-attorney combined with her education in bioethics enables a unique contribution to nursing ethics, law and policy. She is an international speaker on the Code of Ethics for Nurses and an Associate Editor for the Journal of Bioethical Inquiry. Liz is currently an American Academy of Nursing Jonas Health Policy Scholar.

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© 2019 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2019


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