Nurses and other health care workers are often exposed to inappropriate patient sexual behavior (IPSB). Johnson and colleagues define IPSB as any “verbal or physical act of an explicit, or perceived sexual nature which is unacceptable within the social context in which it is carried out.” [1] IPSB encompasses a spectrum of behaviors including: gesturing, giving romantic gifts, making suggestive remarks, propositioning, exposing genitalia, unnecessary touching, with some of the more extreme cases resulting in sexual assault and rape. [2]. It is imperative to note that when a patient’s behavior creates a hostile or intimidating work environment for any health care worker, as in its extreme manifestations, IPSB falls under the legal classification of sexual harassment, a form of sex discrimination that violates Title VII of the Civil Rights Act of 1964 [3]. The definition of IPSB and how it relates to sexual harassment is not clear in existing literature. Not only are these terms unclear in and of themselves, but they are frequently used interchangeably. When IPSB is recognized as sexual harassment, it can imply patients as adversaries creating a difficult care environment. Sexual harassment by patients is a significant problem for general healthcare professionals; however, nurses consistently report sexual harassment by their patients more than any other healthcare sector [2]. This is particularly poignant given that nursing is predominantly female and that we are in the midst of several international campaigns increasing the awareness of sexual assault and harassment. Additionally, the Joint Commission has issued a Sentinel Event Alert on physical and verbal violence against healthcare workers, including sexual harassment, which calls to enforce workplace policies that keep nurses and other healthcare workers safe [4].

The emotional repercussions of sexual harassment include but are not limited to frustration, embarrassment, fear, anxiety, shame, depression, diminished self-esteem, and isolation by the victim [5]. The confusion and self-blame that often accompanies these emotions can then lead to psychological distress. For healthcare providers, inappropriate sexual behavior has been shown to impact ability to function, which can ultimately result in patient avoidance or neglect [6]. This is especially concerning in nursing given the level of care that we provide. While experienced nurses may have learned over time how to cope with toxic work environments, nursing students may lack the skills to navigate through such patient situations while simultaneously learning how to be a nurse. High levels of stress can affect learning, performance, and retention in nursing programs [7].

Creating psychologically safe environments can increase the effectiveness of teaching strategies [8] so it is crucial to consider aspects of psychological safety when designing any intervention related to nursing education. Thus, any interventions must take psychological safety into account (e.g. role-playing or simulation experiences). If nursing students are unable to feel engaged or if they feel unable to share ideas or concerns without fear of negative consequences, psychological safety will be compromised and learning will not be optimal. Nursing needs a theoretical framework from which to identify clear definitions and modifiable risk factors so that we can further empower our profession without causing undo harm to our patients that we serve, protect our nursing students with appropriate tools and aim to prevent IPSB in the future.

References

1. Johnson C, Knight C, Alderman N (2006) Challenges associated with the definition and assessment of inappropriate sexual behaviour amongst individuals with an acquired neurological impairment. Brain Injury 20: 687–693. [crossref]
2. Cambier Z (2013) Preparing new clinicians to identify, understand, and address inappropriate sexual behavior in the clinical environment. Journal of Physical Therapy Education 27: 7–14.
3. The U.S. Equal Employment Opportunity Commission. Sexual harassment. https://www.eeoc.gov/laws/types/sexual_harassment.cfm. Accessed 1/29/2019.
4. The Joint Commission (2018) Physical and verbal violence against health care workers. Sentinel Event Alert Pg No: 1–9. [crossref]
5. De Mayo RA (1997) Patient sexual behaviors and sexual harassment: a national survey of physical therapists. Physical Therapy 77: 739–744. [crossref]
6. O’Sullivan V, Weerakoon P (1999) Inappropriate sexual behaviours of patient towards practicing physiotherapists: a study using qualitative methods. Physiotherapy Research International 4: 28–42. [crossref]
7. Vermeesch A, Barber H, Howard L, Payne K, Sackash C (2016) Road Less Traveled: Stresses and Coping Strategies of Nursing Students. Nurse Educ 41: 117. [crossref] 
8. Henricksen J, Altenburg C, Reeder R (2017) Operationalizing healthcare simulation psychological safety. Society for Simulation in Healthcare 12: 289–297. [crossref]