Patient/Visitor-Perpetrated Sexual Harassment: Supporting Healthcare Workers

Sexual harassment (SH) amongst healthcare professionals has long been identified as a legitimate concern. In fact, it was addressed by Florence Nightingale in the 1860s with the establishment of her first nursing school where she ensured that the nurses’ sleeping quarters were totally separate from the physicians (Wagner et al., 2010). Nonetheless, instances of sexual harassment originating from patients, or their visitors, are unfortunately prevalent. Yet, these occurrences often tend to be downplayed or disregarded. Many healthcare workers (HCWs) commonly share the sentiment, “It’s just part of the job” when recounting such experiences.

Healthcare professionals form unique bonds with their patients. They consider themselves privileged to be present for patients and their visitors as they navigate through some of the most difficult and challenging life events. HCWs often find themselves caring for patients in intimate ways which require a significant amount of trust between both parties. Thereby, when HCWs are forced to contend with inappropriate behavior from patients and/or their visitors, it places them in awkward and uncomfortable positions.

This article will discuss sexual harassment within the healthcare construct regarding healthcare workers (HCWs) and patient/family relationships. The reader will understand what constitutes sexual harassment via a definition and common examples and the inherent challenges of contending with sexual harassment within the sensitive patient/caregiver relationship. The discussion will consider effective ways to respond and support other co-workers and best practices for organizations to support HCWs. Finally, the article will present lived examples from deidentified conversations with HCWs, some of which are aggregates of multiple experiences.

Review of the Literature

A review of the literature identified 30 articles as potential resources for this discussion. After review, 11 were selected as most relevant to the topic (see Tables 1, 2, and 3). Among these chosen articles, the focus was on the impact that patient-perpetrated sexual harassment had on HCWs, along with recommendation for healthcare organizations to mitigate the impact on staff.

Table 1. Articles Selected for Review and Synthesis (n = 11)*

*Full reference information on reference list.

The initial part of the discussion will consider ramifications of patient-perpetrated sexual harassment on healthcare workers, as outlined in the left-hand column of Table 2. The conclusion will identify recommendations that healthcare organizations could adopt, outlined in Tables 3 and 3. The profound psychosocial impact of patient-perpetrated sexual harassment is evident. Authors of all articles concurred that these events had a detrimental effect on reported sense of well-being. Emotional exhaustion, depressive symptoms, powerlessness, feeling overwhelmed, physical health issues, and diminished self-esteem were commonly reported effects as documented across multiple studies (Adler et al., 2021; Kahsay et al., 2020; Nielsen et al., 2017; Spector et al., 2014). The articles did not delve into the level of support HCWs received from their peers nor did they discuss whether these events were reported and the organizations response.

Some articles delved into the level of support HCWs received from their peers or supervisors (Again, let us know which article to reference here, 3 or 4 if possible). Some (most) (no) articles explored whether these events were reported. (Let us know what is the most accurate way to say this, i.e. some, most or no articles. If you choose some or most, again, provide references for this assertion).

Editor: I changed the sentence it was not written correctly – Sallie, in my latest review of this in Dec 2025, I don’t see your response to this highlighted part – can you add this information in? Jackie

Table 2. Literature Support for Psychosocial Impact on Healthcare Workers Article: Synthesis Table by Article

NOTE: These articles correspond numerically as listed in Table 1 above)

Definition of Sexual Harassment and Examples

Sexual harassment is defined as “unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature” (U.S. Equal Employment Opportunity Commission [EEOC], n.d., para. 2). This conduct can occur in any setting and may take many forms, ranging from subtle behaviors to overt acts. Sexual harassment is commonly categorized into three types: verbal, non-verbal, and physical behaviors, which can include inappropriate comments, gestures, touching, propositions, or any unwanted sexualized attention (EEOC, n.d.).

Verbal sexual harassment occurs when another person says inappropriate or offensive comments that make the recipient uncomfortable. Examples of verbal sexual harassment include unwarranted personal questions; sexually explicit jokes or language; and asking the HCW out on a date or making comments about personal appearance. Non-verbal sexual harassment can include glaring stares; looking over one’s body; blowing kisses; and sharing explicit pictures. Physical sexual harassment can include inappropriate gestures; touching in an uncomfortable way; someone exposing body parts; and deliberately brushing up against a person (Gabay & Shafran, 2020).

There can be a fine, undefined line between physical sexual harassment and sexual assault. Although this article does not address sexual assault, it is important to appreciate that the entire realm of SH is truly subjective. Moreover, even though the SH behaviors listed above are not inclusive, these examples help our healthcare colleagues better identify what denotes SH. This recognition is an essential first step for HCWs to protect themselves, to respond appropriately, and to not relinquish their power to the patient.

Discussion and Supporting Exemplars of HCW Experiences

Reporting Experiences
To date, there is very little acknowledgement by healthcare organizations regarding patient or visitor perpetrated sexual harassment. A meta-analysis that reviewed 33 studies of over 18,000 nurse participants showed that 28% reported experiencing sexual harassment (Spector et al, 2014). However, this prevalence rate is most likely underestimated as healthcare workers are often reluctant to name it as such. Surveys may avoid using the term ‘sexual harassment.’ Instead, questions ask, “Have your patients every spoken to you in an offensive way?” Due to the reluctance to specifically name it as SH, the indirect questioning shows a much higher prevalence than merely asking directly about sexual harassment from patients (Ilies et al, 2003). The following exemplars contain deidentified (e.g., location changed) and aggregated scenarios to illustrate the difficulty in accurately determining how to classify experiences. Comments in quotations are used to illustrate examples of responses but do not represent exact quotation from any one person.

Example: I worked in Labor and Delivery in a small community hospital for eight years. I moved to another location and for years never looked back. Until one day another nurse and I were discussing sexual harassment, she asked me if I had ever experienced it, I quickly denied and adamantly stated, “NO.” As she described her experiences of being sexually harassed, a variety of memories were triggered for me, I was able to count 12 distinct episodes of sexual harassment in the time I worked that job. Years later another discussion concerning sexual harassment ensured, and as I explained to a new co-worker my own experiences, he exclaimed, “That is not sexual harassment, that was assault!” I realized then, that not only had I blocked my experiences but even with the acknowledgement they occurred I continued to diminish their impact.

Example: A seasoned CNA who had been working in homecare for 20 years was taking care of a patient with paraplegia. He had been asking her personal sexual questions. She refused to answer and redirected him. His wife came into the room and continued the inappropriate questioning. The CNA was firm at saying this is inappropriate and refused to answer. As she was making his bed, she asked him to move, he refused. When she bent over to try and pull the sheets, she realized his face was very close to her bottom. Then she realized his face had always

that close. She jerked up in disgust, demanded he move, or she would be unable to finish. He laughed as he and his wife invited her to join them in a threesome. She had had enough. She went to her car and cried. She questioned herself. She always wears a T-shirt under her scrubs and wears loose fitting scrubs. Could she have set boundaries better, been stricter? What else could she have done?

It is no wonder that both HCWs in the prior two scenarios were unclear about whether they were being sexually harassed, unsure of how to proceed, and ultimately questioned their own behavior. Below I discuss potential outcomes of SH at the individual level and actions for leaders and colleagues at the systems level.

Potential Impact of Experiences
Individual Level Outcomes. Healthcare workers are often exposed to intimate care situations and difficult life circumstances with patients. A bond is formed. When the patient or their family violates that bond, through inappropriate comments or behaviors, it can be devastating and humiliating for the healthcare professional. Many HCWs who fall victim to patient-perpetrated sexual harassment often blame themselves and feel guilty about the untoward feelings they are experiencing for the perpetrator. Sexual harassment from patients causes significant harm to HCWs including depressive symptoms, feelings of powerlessness, low self-esteem, impaired well-being, emotional exhaustion, and psychosomatic complaints (Adler et al., 2021).

A systematic literature review (Kahsay et al, 2020) found that sexual harassment against female nurses caused mental, physical, emotional, psychological, and social health consequences. The feeling of helplessness caused fear and anxiety among the nurses and ultimately created a toxic work environment. Findings from this review demonstrated that sexual harassment had led to physical health symptoms that may include exhaustion, headaches, gastrointestinal problems, nausea, vomiting, and weight loss or gain. The nurses also often exhibited sleep problems. (Kahsay et al, 2020).

Everyone experiences sexual harassment differently, they bring their culture, history and lived experiences with them. Each person deserves respect and validation for how they perceive an experience.

Example: “One of my home health patients was a 41-year-old quadriplegic and every time I would perform catheter care he would make sexually charged comments. At first, I was really upset, but I got used to it and just would laugh it off. What else could I do he was my patient?”

Many HCWs have been conditioned to tolerate sexual harassment, some may laugh it off, some may ignore it, but until HCWs take a stand of zero tolerance, they lose their power and feel a sense of helplessness in the situation (Notaro et al., 2020). We need to train and empower HCWs to stand tall, and with a straight face say, “Stop!” HCWs can re-direct behaviors by saying, “Let’s keep this professional” or “Today we are focusing on you and your care” (Notaro et al., 2020). There may be an uncomfortable feeling in the room afterwards, but it is okay to allow the patient to sit in that awkward moment. HCWs need to take their power back and they have every right to do so. The exemplar below illustrates this action, but still with reservations by the HCW.

Example: “He put his hand on my inner thigh. My immediate reaction was to slap it away, which I did. A few weeks later, this happened again, I grabbed his hand tightly and told him to never touch me there again. I was afraid I might have bruised his hand or that I would get in trouble for hurting him. I apologized to him. I felt sick and never wanted to go back, but I still did.”

A qualitative study conducted in Korea (Kim et al., 2018) demonstrated the universal difficulties in these encounters. Professional interviewers worked with student nurses to explore their experiences with sexual harassment from patients. The study shared the student comments regarding their experiences: I was “just standing there without knowing what to do” (Kim et al., 2018, p 382).  and “It was creepy, and I was disgusted. I couldn’t say anything because I was so surprised” (Kim et al., 2018, p 383).

Sometimes the healthcare worker may be so shocked and disgusted that they do not know how to respond. HCWs should be empowered to leave. They are not encouraged to stand there and be hit or yelled at by patients. Why would they think it is ok to take sexual comments or actions that make them feel disgusted? These actions should not be tolerated. Abusers will never stop, until the abused demand to be treated with respect. This in no way puts responsibility for what happened on the victim but should empower them to know they deserve respect.

The shock from inappropriate gestures or comments often leaves healthcare workers surprised and not knowing what to do or say next. HCWs need to be empowered and taught to respond in ways to stop the sexual harassment. They also need to know that their institution leaders stand behind them in providing a safe work environment. The next section considers systems level outcomes and recommendations.

Potential Systems Level Actions. It is incumbent upon our healthcare systems to acknowledge SH as a legitimate problem, and to develop effective strategies to manage these concerns. Supporting each other through difficult work experiences, and particularly sexual harassment, is critical to mitigating the negative mental and physical health effects described by HCWs (Nielsen et al, 2017). Important questions to consider are whether perceived lack of processes and support for these employees could be an overlooked, major contributor to nursing burn-out and would working to resolve these issues decrease the rate of turnover now seen in healthcare.

When co-workers share their SH experience with you either as a fellow colleague or their supervisor, there are three basic principles to follow to ensure your HCW feels adequate support, Katbat-Fatt and Crumley (2019) have described these as belief, validation, and victim blaming. The created examples below illustrate what you may hear HCWs say or their possible actions:

(SALLIE: I am assuming the part in italic is your creation to illustrate these principles and not direct quates from the Katbat_Fatt & Crumley article. IF that is correct, we don’t need to do anything. IF they are quotes from the article, we need to cite the page numbers. Just making sure. Jackie)

1. First, always believe them. It is important to show support by believing the HCW who reports an occurrence of sexual harassment. The example below illustrates the perceived fear that can keep an employee from reporting.

Example: “I believed that in reporting these instances of patients being inappropriate with me, nothing would be done, I would be seen as a troublemaker, and it would affect my ability to move up in the organization.”

Managers should always believe and support staff. The manager’s response is an important step toward healing for the HCW. Managers need to help staff to understand all the resources that are available to them. For example, one can offer staff employee assistance program (EAP) counseling, support with reporting, and whatever else they may need. Allow staff members to choose the course of action that feels right for them. It is also important to check back with them both a few weeks out and then a few months later. Knowing that someone cares is one way of healing.

2. Next, focus on validating feelings. It is important to avoid joking or condescending remarks that can lead to perceptions of no support from colleagues and/or supervisors.

Example: “When I told my co-worker what had happened, she laughed and said I needed to use my karate moves to protect myself. I was incensed, to have this patient grabbing me is not OK. I felt unsupported and embarrassed.”

3. Finally, avoid victim blaming. Place the responsibility on the perpetrator; it is likely that the victim is already self-blaming.

Example: A caregiver shares that during a recent visit, both the patient and his partner were asking her sexually charged questions. She explains that she tried to redirect them, but they just laughed at her discomfort. She blames herself for the situation even though she is unclear as to what she did to cause this to happen.

There are often extenuating circumstances for which to consider and prepare. As mentioned previously, common responses amongst HCWs to SH occurrences are often self-deprecating and usually include making excuses for the patients and/or visitors’ behavior. This may be particularly true if the patient or visitor is exhibiting cognitive impairment. Cognitive impairment can affect a patient’s filter and may increase inappropriate comments or actions. Those suffering from dementia, traumatic brain injury, and other mental impairments may require a different approach. It is effective to redirect them while firmly setting boundaries. For example, one organization dealing with traumatic brain injury patients uses stuffed animals. Patients are encouraged to touch them inappropriately, which in turn removes the focus from staff (Fenwick et al, 2021).

In sum, this section has provided a brief overview of potential individual outcomes and systems level recommendations. Table 3 below lists in the left-hand column recommendations for healthcare organizations contained in these articles related to potentially useful actions from the administrative team to support HCWs who have experienced SH.

Table 3. Recommendations for Healthcare Organizations Articles: Synthesis Table

NOTE: These articles correspond numerically as listed in Table 1 above)

Employee Education
Stepping Away. Patient safety is always paramount, and patients need to be in a safe place; however, the HCW’s well-being and safety is also vital. HCWs have an obligation to ensure the patient is safe. They also need to be empowered to leave uncomfortable or threatening situations whenever possible, and to know and understand the appropriate actions to take. Upon leaving the situation, HCWs should reach out to co-workers, supervisors, and utilize established escalation processes within the institution. One such process published by the Occupational Safety and Health Administration ([OSHA], 2015), offer federally recognized guidance on responding to workplace violence and unsafe situations that includes the following steps:

• Recognize discomfort or danger
• Leave the room
• Seek assistance
• Report to supervisors
• Use EAP and security resources (OSHA, 2015)

Other important content areas to provide training for HCW about how to best respond in the event of SH from a patient or visitor are listed in the left-hand column of Table 4, which identifies appropriate support from the reviewed literature. Note that many of these actions have been included in the discussion and exemplars above; others are further discussed below. The critical steps are to assure that HCWs receive education before an event occurs, and support afterwards.

Table 4. Recommendations for Training Healthcare Workers Articles: Synthesis Table

NOTE: These articles correspond numerically as listed in Table 1 above)

Bystander Support. It is noteworthy that survivors of sexual assault often emphasize the importance of receiving an understanding and empowering response from the first person they confide in. Such a response has been shown to significantly influence the processing and healing from the abuse. We need to believe and support each other (Kabat-Farr & Crumley, 2019; Senapati, 2021).

Bystanders may play an important role in supporting HCWs and stopping inappropriate behaviors. A bystander is anyone who observes an event taking place but isn’t directly involved. Bystanders must be empowered to interrupt sexual harassment and or violence, by training them how to safely become involved (Senapati, 2021). Some of the best examples of bystander intervention is on college campuses dealing with sexual assault. Colleges have demonstrated that by training bystanders on how to recognize, intervene and demonstrate empathy towards possible victims, they have increased bystander intervention to stop assaults before they happen. This has also shown an increase in survivor reports and survivors seeking further help and support on their healing journey (Kabat-Farr & Crumley, 2019; Senapati, 2021).

Employee training programs need to include those items mentioned above, as well as training HCWs on how to stand up and set boundaries. Training for managers and co-workers should include how to support and empower each other, and how to respond with empathy.

Policies and Messaging. Every healthcare organization must improve their responses to these SH instances (Kabat-Farr & Crumley, 2019). One of the approaches used at Massachusetts General, a top hospital in the United States, was to strengthen the message sent to patients through updates to their patient code of conduct. These changes included statements that they would not tolerate racist, discriminatory, hostile, or harassing behaviors. The code of conduct also forbade offensive comments about race, accent, religion, sexual orientation, physical or verbal threats, and sexual or vulgar words or actions. Moreover, they advised that any patient that violates this code, will be offered an opportunity to explain and may also be asked to seek healthcare elsewhere (Carbajal, 2022)

Messages such as this can be powerful not only to improve the situation, but also to empower HCWs and help them feel supported and validated. Mass General is the first in the state of Massachusetts to implement a patient code of conduct that specifically addresses sexual harassment behaviors. This should be the standard not the exception. (Carbajal, 2022)

The Equal Employment Opportunity Commission (EEOC) and the federal courts have provided directions for healthcare. According to EEOC guidance, employers may be liable for harassment by non- employees if they knew (or should have known) of the conduct and failed to take prompt corrective action. (U.S. Equal Employment Opportunity Commission, n.d.). Employers worry about the bottom line from a financial perspective and the patient’s response; however, they must recognize that real liability lies with the employer who fails to respond appropriately to a HCW’s claim of patient/visitor perpetrated sexual harassment (Moore et al., 1999).

Strategies for Support. Organizations may improve structural interventions that not only prevent or reduce the incidence of sexual harassment, but also adopt strategies that will mitigate or alleviate the adverse effects of sexual harassment (Adler et al., 2021). One example is to evaluate the organizational reporting system from the perspective of patient-perpetrated sexual harassment. Several questions to ask include:

• Does it empower or victim blame in the way questions are asked?
• Is the reporting system easy to access and use?
• Does the victim feel empowered and validated when reporting?

Another opportunity is to ensure that the organizational culture demonstrates that HCWs deserve to be treated with respect by colleagues and patients/visitors. This must be a top-down initiative. Employee Assistance Programs can be strengthened to support survivors. Another strategy is to improve manager training on appropriate response, as well as how to access resources to support HCWs. Creating a checklist for managers can be extremely helpful (Nielsen et al., 2017).

Conclusion

Most healthcare organizations have systems in place to address workplace violence. These systems work well with an angry, threatening patient but fall short with patient-perpetrated sexual harassment. Stepping back and speaking softly does not work to stop sexually explicit behaviors (Spector et al., 2014; Gabay & Shafran Tikva, 2020). Organizations must identify all areas including training, manager support, structure, culture and reporting systems to improve the way they support and protect HCWs against sexual perpetrators

In 1993, the American Nurses Association (ANA) in their position statement acknowledged “ANA believes nurses have a right to and a responsibility for a workplace free of sexual harassment” (ANA, 1993, Para X) (AUTHOR: Please provide a full reference for this from the webpage of the ANA where this is located, or the hard copy publication, if not online. We will also need the page or paragraph number where the quote is located to add in the parenthetical citation. Thanks!). Editor: I cant find good enough supporting quotes for this only a secondary source. Can I use the following? (Sallie: I can’t find this either, so we can use a secondary source that you provided below but we cannot use the quote from ANA without putting a page or paragraph number. To fix this, I paraphrased it instead (below in the next paragraph). That will have to do. Jackie)

According to Ross et al. (2019), the American Nurses Association, had published as early as 1993 a position statement that called to eliminate sexual harassment of nurses in every setting of employment. They noted that sexual harassment has an adverse impact on the healthcare environment. It has been over 30 years since this statement and sexual harassment continues to be a problem for healthcare workers. Institutions have an obligation to address this concern for their staff. SH is not going away; our healthcare systems have the power and influence to protect and support all healthcare workers.

Every healthcare organization must take the needed steps to strengthen the response to patient perpetrated sexual harassment. Minkina (2019) argued that healthcare workers must speak out to defend their rights, and that the shame for harassment belongs solely to the harasser — not the victim.

In conclusion, based on a review of the literature noted above, healthcare organizations should start with these steps:

• Implement and reinforce a zero-tolerance policy towards sexual harassment.
• Enhance the existing reporting system, ensuring its safety, simplicity and effectiveness in addressing the issue.
• Educate staff on recognizing, responding to, and reporting instances of patient perpetrated sexual harassment.
• Provide training to managers and co-worker on how to support and empower HCWs.
• Communicate clear expectations to patients regarding respectful treatment of all staff members.

By collectively addressing these concerns, we can foster an improved work environment and continue our commitment to protect and support all healthcare workers from experiencing sexual harassment from patients and visitors in the facility.

Author

Sallie Calder, RN, MSN
Email: Sallie.Calder@gmail.com

Sallie Calder graduated from Brigham Young University with an associate degree in nursing at the age of 20. Nursing has been her passion for over 40 years with a variety of experiences in the emergency department, labor and delivery and medical-surgical units, and has worked in such areas as research, behavioral health, clinic supervision, education and more. She considers it a privilege to be a nurse, with many beautiful, soul stretching experiences throughout her career.