Overview and Summary: Sexual Harassment in Healthcare

Florence Nightingale tried to control male physicians and surgeons’ sexual harassment of her nurses in the 1800s. Her approach was one of prevention - each nurse had to be of high moral character, thereby implying that nurses were to blame for their own victimization, which was the thinking of the time. Nightingale also required the nurses to live in separate residences where they would be away from the physicians and would not be stressed with threats of harassment. In addition, they had to abide by a curfew, dress in restrictive clothing, and behave in a ladylike manner. Florence believed the rules provided a coping strategy for the nurses to deal with male putdowns while demanding respect for the nurse who worked outside the home - the role of a lady.

The first known published comments of women dealing with sexual harassment at work came in a 1908 Harper’s Bazaar edition where women wrote in about their experiences of “life in the city” (Harper’s Bazaar, 1908). Many of these published letters discussed their sexual harassment, though the term was non-existent at the time.

Sexual harassment, though a relatively modern term, is a centuries old phenomenon. Sex discrimination has only been illegal since the Civil Rights Act of 1964 (1964). Even then, it wasn’t until the 1970s that the first sexual harassment lawsuits entered the courts (Cohen, 2016), and the U.S. Supreme Court did not opine that sexual harassment was a form of sex discrimination until 1986 (Meritor Savings Bank vs. Vinson, 1986). In 1991 Congress modified Title VII to allow victims of sexual harassment the right to collect compensatory and punitive damages (Civil Rights Act, 1991). The year 1994 gave us the Violence Against Women Act (1994), and it wasn’t until 1995 that Congress was subjected to the same laws as the rest of its citizenry through the Congressional Accountability Act (1995). But perhaps it has taken the #MeToo movement to bring us where we are today.

Sexual harassment stories in healthcare have emerged in the news even before the current #MeToo movement. While there is no #MeToo movement in Nursing, there is a #MeToo movement in Medicine. The National Academies of Science, Engineering, and Medicine ([NASEM], 2018) lists five stipulations in which sexual harassment is likely to occur: a) perceived tolerance for the misconduct, b) environments where either men outnumber women, leadership is male dominated, or the jobs are atypical for women, c) hierarchical power structures, d) “symbolic” compliance with Title VII or Title IX, and e) lack of leadership to address sexual harassment. Considering these five antecedents, perhaps it is time for nurses to establish a #MeToo in Nursing movement.

Effectively preventing sexual harassment requires transformational leadership. It is not enough to use piecemeal approaches such as training, an effective policy, and zero tolerance, though important. While those are some of the strategies to which to engage, they will not change the gendered status quo existing in healthcare. Sexual harassment is a systemic and pervasive problem within healthcare, not a series of random acts. As a result, to change the abusive gendered healthcare culture, it requires a systemic, holistic approach to change management. As nurses, we are the largest healthcare professional group; we are bright, know the healthcare environment and culture, and are best positioned to not only be the catalyst for change, but to be the changemakers!

The article, “Sexual Harassment in Nursing: Ethical Considerations and Recommendations,” by Ross, Naumann, Hinds-Jackson, and Stokes introduces sexual harassment as a form of workplace violence, as defined by the National Institute for Occupational Safety and Health (NIOSH). The authors also use the Equal Employment Opportunity Commission (EEOC) definition of sexual harassment while providing a comprehensive list of sexual harassing behaviors. Using the definitions by NIOSH and the EEOC, the authors discuss the ethical elements associated with the misconduct, including introducing the Code of Ethics for Nurses by the American Nurses Association. Sexual harassment is a human rights violation as well as the antithesis of the Joint Commission’s leadership and patient care standards, as outlined by the authors. Implications for nurses as it relates to the sexual harassment by patients is a common problem discussed. Importantly, the authors provide a complaint process nurses could use if victimized by the abuse. Implications and recommendations necessary for healthcare organizations and nurses to diminish the incidents of sexual harassment are spelled out.

We have all seen the sexually offensive Halloween costumes of the female (not male) nurse. Authors Escobar and Heilemann discuss media stereotypes in their article, “Reimagining Nursing On Screen: How Marvel’s Claire Temple and BBC’s Call the Midwife Get It Right.” The authors’ framework uses two television shows as reflected in the title of their article. Using the two shows, they demonstrate how media can indeed “get it right.” While the two shows depict nurses in different generations – the 1950s and 21^st century - they are strong women despite each era’s mores. Nurses in both programs “bend and break” stereotypes of nurses, who are most often women. The article discusses the conflation of women to nursing which can be problematic since women have lower status in society that can then be applied to nursing. The authors explore three issues: a) gender and sexual identity of nurse depictions, b) motivations behind characters actions, and c) how nurse characters provide which types of clinical care. The article concludes by identifying steps that nurses can take to combat the negative nursing stereotypes in the media.

What does the research suggest regarding how nurses and other healthcare professionals respond to sexual harassment around the world? The article by Draucker, “Responses of Nurses and other Healthcare Workers to Sexual Harassment in the Workplace,” provides an integrative review of 15 studies from around the globe outlining the serious impact of sexual harassment. Draucker discusses how this form of workplace abuse impacts nurses and others within the healthcare milieu. She evaluated the data from these studies and found that victims experience three broad types of repercussions: mental health impact, physical health impact, and employment impact. The impact, responses, and coping mechanisms for nurses and other healthcare professionals varies widely from ignoring the harasser to developing post traumatic stress disorder. Draucker considers all in her analysis of the 15 articles.

Perhaps one of the most serious negative consequences a nurse can experience when victimized by sexual harassment is the psychological impact to well-being. Identifying the antecedents and environmental aspects as a foundation for the psychological perspective, Kabat-Farr and Crumley, in their article “Sexual Harassment in Healthcare: A Psychological Perspective,” delve into the hierarchy of healthcare and the challenges of reporting one’s victimization. The authors categorize sexual harassment into three broad sets of behaviors: sexual coercion; unwanted sexual attention; and gender harassment, the most frequent form of harassment and the most ignored. Three general frameworks are considered in the authors’ discussion as to why sexual harassment occurs in healthcare: to protect one’s status, a rich history of hierarchy, and isolated environments. Studies vary as to who is the most likely perpetrator. Some research suggests it is the physician while others indicate it is the patient or relatives. The article addresses basic organizational tenets that must change to reduce the incidents of sexual harassment. It is not likely that nurses will report their sexual harassment experience for the myriad reasons discussed in the article.

Unless we have been in the military or married to a military spouse, most of us are unfamiliar with how their rules and regulations regarding sexual harassment differ from civilian rules and regulations. The media has been rife with stories of sexual harassment in the military throughout the years which may lead us to believe those egregious stories are the norm. According to Colmore, Culver, Lee, and Kidd, in their article “Sexual Harassment in the Military: Implications for Civilian Nursing Policy,” the military has taken the bull by the horns in their prevention and intervention strategies. The “military” is much broader than just the Army, Navy, Air Force and Marines; it encompasses the Coast Guard/Department of Homeland Security, U.S. Public Health Service/Department of Health and Human Services, and the National Oceanic and Atmospheric Association Corps/Department of Commerce. The authors provide the military definition of sexual harassment, which is almost identical to the civilian definition. The process of addressing sexual harassment complaints is identified considering how data is collected, processing the complaint, training and responsibility. Comparative analysis of military and civilian aspects – specifically the EEOC – is addressed with the authors offering suggestions on how the civilian approach to dealing with sexual harassment may glean important guidance from the military approach.

The final article written by Castner, “Healthy Environments for Women in Academic Nursing:  Addressing Sexual Harassment and Gender Discrimination,” explores the academic environment. As the author points out, the empirical literature addressing the sexual harassment of student nurses within a university setting is minimal. As a result, Castner reviews sexual harassment to women in academe, asserting that they experience the second highest rates of sexual harassment and discrimination in the workplace, with military women in the number one spot. Castner explores both direct and indirect harassment and how both forms negatively impact women’s careers. Hostile and benevolent sexism are addressed examining benevolent sexism as a realistic experience for nurses. Castner examines the bias in collaborative work, gender and race, organizational risk factors and the academic culture. As is evident in the healthcare environment, hierarchy and power structures are the foundation for sex discrimination and harassment in education as well. Often, there is the perception by students, faculty, and the public that academe is in compliance with the law and best practices. However, as Castner notes, often the compliance is only superficial and not a reality. Solutions and organizational strategy are challenges in designing and implementing an effective prevention and intervention strategy to minimize the sexual harassment of female students and faculty.

The journal editors invite you to share your response to this OJIN topic addressing Sexual Harassment in Healthcare either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.

Author

Susan Strauss, EdD, RN
Email: susan@straussconsulting.net

Susan has been an RN in a variety of nursing specialties, as well as the director of quality improvement and director of education and development. One of her specialty areas is bullying and harassment in healthcare- working as an expert witness for lawsuits, training, and conducting investigations. She has researched physician abuse to RNs in the OR to determine if the abuse varied based on the gender of the nurse. Dr. Strauss has authored over 30 books, book chapters, and articles, as well as written curriculum and training manuals.