Journal of Women's Health Care
Open Access

Factors associated with sexual harassment towards women nurses: A systematic review

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Introduction

Background

Harassment and violence against nurses are complex and persistent occupational hazards facing the nursing profession. This happened at the opposite end of the professional mission to care for people, which appears to be at the highest risk of workplace violence [1]. The nurses’ job involves working physically and emotionally close to patients and other staff members; nurses are more exposed to offensive behaviors at work than other employees [2, 3]. A worldwide report showed that about one in four nurses were exposed to sexual harassment [2]. Specifically, researchers have argued that nursing is the profession with the highest rate of sexual harassment against women nurses [3].

Sexual harassment is unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct sexual contact that are directed toward a person in the workplace [4]. Harassment may include unwelcome verbal, visual, nonverbal, or physical conduct that is of a sexual in nature or based on someone’s sex [5]. The perpetrator is a harasser, who may be a woman or a man [6]. A woman nurse in this review is a female in gender who graduated as a nurse and was assigned to provide care for healthy or ill clients.

Sexual violence and harassment are prominent aspects of workers’ lives, particularly for women workers around the world, and sexual harassment is the most reported form of violence [7]. Researchers recognized it as a widespread social and legal issue that especially affects women in a range of settings [8]. The National Academies of Science, Engineering, and Medicine listed stipulations in which sexual harassment is likely to occur: perceived tolerance for the misconduct; environments where either all men outnumber women, leadership is male-dominated, or the jobs are atypical for women, hierarchical power structures; and a lack of leadership to address sexual harassment [9].

Women working in man-dominated jobs have more experience with sexual harassment. Several studies suggest that women working in woman-dominated jobs also have a higher risk of sexual harassment. The occupation prone to harassment is the nursing profession [10]. A study confirmed the persistence of sexual harassment among women working in the health sector. Power dynamics in the hospital setting make working women, notably nurses, junior doctors, and nonmedical staff, particularly vulnerable to victimization [11]. Looking back on nursing history, Florence Nightingale and the American Nursing Association ostracized men from the nursing profession until 1930 [12]. The proportion of men in the nursing workforce has remained fairly constant from 2011 to 2018, at around 10% in the United Kingdom. Despite those women nurses outnumber men by a ratio of 19 to 1 [13]. The United States Census 2006 report indicated that men only constituted 7% of the workforce in nursing [14].

Researching sexual harassment in the workplace is in its infancy, but surveys have found that 40–50% of women in the European Union countries reported a sexual harassment or unwanted sexual behaviors in the workplace [15]. According to a study, one in three women between the ages of 18-34 had been sexually harassed at work, but only 30 percent reported it. Those young workers in their first or second jobs may be less aware of laws and workplace norms [16].

In the nursing profession, an incidence of sexual harassment was reported in which a male nurse attempted to harass a female nurse sexually on the night shift in the operation room of a private tertiary care hospital in Pakistan [17]. So, women nurses are susceptible to sexual harassment in the workplace. This is especially true considering that many nurses cannot report incident of harassment, no matter who is at fault. Many women nurses have developed thick skin and are labeled as having suggestive behavior for sex that doctors, patients, and other nurses may impose on them [18].

According to Malaysian workplace reports, victims can be the motivators of sexual harassers, with the perception of attractive physical appearance as an influencing factor. Besides this, overcoming internal inhibitions against harassment, working in a private workspace, and overcoming victim resistance were other factors. Some other reasons for sexual harassment are the educational background of women workers, the unprofessional working environment, and working with male workers [19]. According to the European Commission report, other personal characteristics that influence the likelihood of harassment are age and marital status: younger women, aged between 20-40, and single or divorced women are more likely to be harassed than other women [10]. Interestingly, research studies on harassment show that women in supervisory positions are more likely to be harassed than women in subordinate positions. Over half of the supervisors reported harassment, compared to about a third of those in lesser positions [20].

Many hospitals overlook harassment committed by their most accomplished physicians, even when reported [21, 22]. Sexual harassment by co-workers as well as patients is also an issue that has received less attention considerably than other forms of physical and nonphysical violence [2].

Since nurses are involved in the personal care of individuals of the opposite sex, there is sometimes the unspoken assumption that nurses will not be offended by sexual comments, jokes, or innuendo [23]. In addition to this, many nurses also are not aware that their employers are often responsible for sexual harassment by a patient or visitor. One of the first steps to holding hospitals accountable for these incidents is to report each one, so employers can take further steps to protect the nurses working in their facilities and maintain a safe work environment [24].

To our knowledge, there is little or no quantitative review of factors associated with sexual harassment towards women nurses that includes an adequate sample of male nurses and women nurses as participants. Most reviews and primary studies focused on the antecedent, perception, history, consequences, and prevention of sexual harassment [21, 25], prevalence of sexual harassment [26, 27], conducted among non-nurse women [25, 28] and majority on student nurses and other graduate students [2, 29, 30]. It is of great importance to review the factors associated with sexual harassment of women nurses. It may help in nurse understand of the factors associated with sexual harassment more clearly by nurses, inform policymaking, get priority attention, and take protective measures. This systematic review was intended to identify factors associated with the experience of women nurses experiencing sexual harassment. The study question was, “What are the factors associated with the experience of women nurse sexual harassment was the study question?”

Methods

Review Protocol

This systematic review was conducted following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta- Analysis Protocol (PRISMA-P 2015) [31]. Electronic searches were completed on 30 December 2018 of the complete databases Scopus (from 2004), Pubmed (from June 1997), Web of Science (from 1997) and ProQuest (from 1972), and from the Google Scholar search engine (from Nov. 2004).

Information Sources

The comprehensive literature search was focused on sexual harassment towards women nurses. Studies were identified by searching for the following electronic databases: PubMed, Scopus, ProQuest, Web of Science and Google Scholar.

Searching Strategy

To identify potentially relevant studies, the following key terms were used in the electronic searches of the databases. For the search on ProQuest was “ti (sexual harassment) or ti (sexual violence) or ti (sexual assault) and ti (factors) or ti (determinants) and ti (women) or woman nurses)”. On Scopus was “sexual and harassment OR violence or assault and factors or determinants and women or woman and nurses”. On Web of Science “TI= (sexual and harassment)” or “TI= (sexual and violence)” or “TI= (sexual and assault)” and “TI= (factors or determinants)” and “TI= (women or woman)” and “TI= (nurses)” with their combinations were used. The advanced search on Pubmed was “(((((([sexual]) and [violence]) or [harassment]) or [assault]) and [factors]) or [determinant])” limited to full free articles and studies on women or woman nurses. From the advanced Google Scholar search was “sexual harassment or sexual violence or sexual assault and factors or determinant and “women or woman nurse” limited to words occur anywhere in the article

Inclusion and Exclusion Criteria

All studies globally conducted on sexual harassment towards women nurse were searched and used in the analysis. The systematic search was from suitable databases to identify potentially eligible articles in the analysis. To screen eligible articles, inclusion criteria were set. The eligible articles included in the review study were: Quantitative studies, studies conducted from the conception of sexual harassment, full text, published in peer-reviewed English journals, determined factors associated with sexual harassment, and among women nurses who were graduated in nursing and working in any health facility to provide care for well or ill clients. But study reported to more than one paper, abstracts, student nurses and other women in non-nursing employment as participants were excluded.

Study Selection

The search identified a total of 7099 records. During the initial screening, 78 duplicate records were removed. Out of the remained 7021 records, 6872 records were excluded based on titles and their abstract. Afterwards, full-text articles (n=149) were independently reviewed if they met the inclusion criteria for this systematic review. Two reviewers used the eligibility criteria to select eligible articles of this systematic review. Out of the 149 articles, excluded articles were: 74 articles on other forms of violence, 38 articles qualitative and review in design, 22 were student nurse as participants, 9 dealt on other health care providers and other women employee participants. Finally, a total of 6 articles were found eligible for this systematic review. The PRISMA flow chart was used in the selection as shown in Figure-1 [31].Discrepancies in article selection of the two reviewers were resolved by discussion. For issues with disagreement, resolved by a third reviewer.

Figure 1. PRISMA flowchart search results on factors associated with sexual harassment towards women nurse [31].

Data Extraction

Before the synthesis of findings, the documents were read thoroughly to gain an initial sense of data. We have highlighted results from individual studies regarding whether associations were seen between specific factors and sexual harassment. Subsequently, the two authors independently identified and recorded the factors that showed an association with sexual harassment in a tabulated datasheet based on the inclusion criteria. The datasheet includes authors’ name, year of publication, study country, study design, the sample size of women nurses, study setting for the study population and the factors associated with sexual harassment. The data extraction data sheet was refined during the extraction of the first few articles to ensure that the sheet was comprehensive. Only studies with some form of statistical analysis using comparison between groups (e.g. cross-tabulations, regression or correlational analysis) which showed an association were included. The first and second authors independently examined the included studies. The first author extracted the relevant data in in the data sheet for each of the articles that were deemed suitable for inclusion, which was cross-checked by the second author. For issues with disagreement, resolved by a third reviewer.

Risk of bias in each study

The Modified Newcastle Ottawa Scale for Cross-Sectional Studies Quality Assessment Tool was used before the analysis to evaluate quality of each article. The tool has ordinal scoring for the following components: the representativeness of the samples, sample size, non-response rate, and use of validated tool, comparability, outcome and statistical test. Each component is rated as 9-10 points in very good study, 7-8 points for good studies, 5-6 points for satisfactory studies and 0 to 4 points for unsatisfactory studies in quality [32]. These articles which scored satisfactory or more (≥5 scores) in quality were included in this systematic review. The two reviewers scored a rating for each article. A third reviewer was involved solving the disagreement between the two reviewers in the rating of study quality. A final agreed-upon rating was assigned to each study stated in Table 1 of the result section.

Table 1: Studies included in the systematic review on factors associated with sexual harassment towards women nurse

Synthesis of results

The synthesis was performed qualitatively for all factors potentially associated with sexual harassment towards women nurse in each study. The qualitative synthesis performed by identifying all independent variables and their categories in the original papers. The categories were coded. The coded categories were combined in a whole via listing of the descriptive of each variable compared across studies in line with the association determined. Then the whole content was described. The study results came with statistical analysis using comparison between groups (e.g. cross-tabulations, regression or correlation) and showed an association at p-value <0.05 was included, and identified as factors associated with sexual harassment. For the purpose of the review, the term ‘factor’ does not imply causality but only an association in each study.

Results

In this systematic review, one or more factor associated with sexual harassment towards women nurse was identified and reported. The number of articles included in the review was six. All of them were conducted on women nurses in descriptive cross-sectional study designs [33-38]. The three (50%) studies used convenience or purposive sampling technique [33, 34, 36]. The rest three studies used systematic sampling [35], random sampling [38] and one quota sampling technique [37] each. Two (33.33%) studies were conducted in Egypt [37]. One study was conducted in each of the following countries, South Korea [33], Japan [35], Malaysia [34], and Turkey [36]. The total number of participants was 3187 women nurse working in 73 hospitals. The Chi square (X2) test was performed in the six studies. Regression analysis was performed in three (50%) of the studies [34-36]. Adjusted Odds Ratio (AOR) and X2 test result at p <0.05 were considered in the association in the studies.

Among the factors associated with sexual harassment identified in this systematic review were sociodemographic factors of the women nurse. The age of women nurse showed an association with the harassment in three (50%) studies [34, 35, 37]. The single marital and educational status showed an association in two (33.33%) of the reviewed studies [36, 37] and women nurse live without child were more exposed to sexual harassment in a study [35]. The work experience also showed an association with sexual harassment in other three (50%) studies [34, 36, 38]. The job title, assistant nurse was also related to sexual harassment in one study [35].

Other factors that showed associations were related to the nurses working conditions or occupational factors. Three studies (50%) showed an association with working units of hospitals and the sexual harassment [34, 37, 38]. The risk of sexual harassment was higher among nurses working in closed units compared with open units [37]. Those worked in the orthopedic or emergency unit were exposed to sexual harassment than working in medical and surgical units, with a statistically significant difference (P=0.020) [38]. In addition to this, that incidents of sexual harassment occurred mostly in the orthopedic unit followed by medical units, surgical units and clinics respectively [34].

One study revealed that sexual harassment was associated with working to shift, and longtime stay at work [38] and more among women nurse reside in the rural than living in urban exposed to the harassment [37].

In addition to all, nurses’ perception of prettiness, perception of having good body shape and their personal relationships with other people were related to sexual harassment [34]. Similarly, nurses perception of their patients’ gender equality was associated with sexual harassment in a study [35] and patients care demand in another study was related with the sexual harassment towards women nurse [33] Table1.

Discussion

This systematic review identified factors associated with sexual harassment towards women nurse. The factors were related to sociodemographic of women nurses, their working conditions, patient care and patient demands, nurses’ perception of good natural body structure, nurses’ personal or interpersonal behaviors.

Nurses’ age less than 30 years was related to the sexual harassment. Sexual harassment was 2 folds higher among these with age less than 30 years compared to the age greater than 40 years. This association is consistent with a finding that younger age of nurses faced sexual harassment higher prevalence in a year [27]. Similarly, this association gets consistency with other studies on sexual harassment among nurses and care workers [25, 39, 40]. Again, age showed a significant effect on incidence of sexual harassment among medical students that suffered being in their 20s [41]. And also the prevalence of sexual harassment was higher among those in age group of 20 to 24 years which supported our review [30]. Moreover, gender harassment by colleagues was also less frequent for age groups greater than 30 years in another study [42]. The perceptions of sexual harassment were varied by age, older victims tend to perceive sexual harassment differently compared to younger ones [28]. Conversely, there was no difference in age on sexual harassment in a meta-analysis among Chinese nurses [26]. This difference could be due to participant gender mix in the previous study.

Our review found that nurses’ marital status showed a significant association with the harassment. The nurse single in marital status was more harassed than married and separated. This finding agrees with the high frequency of sexual harassment among unmarried nurses [40]. It is also in line with a study finding a single mother and mother living alone experienced sexual harassment [42]. In line with our review, single medical staff similarly had the highest percentage of harassment [41], and sexual harassment was also higher against single graduate women student than married [30].

The educational status of the participants showed controversies about its association with sexual harassment. Nurses with Associate Degree in education were exposed to sexual harassment higher than those with Bachelor of Science in nursing or Diploma educated. Conversely, those with Bachelors of Science in nursing education were highly sexually harassed than Vocational Health High School in nursing education. This difference could be due to the inconsistent use of educational level in nursing studies. Supporting these disagreements, education did not influence perceptions of prevalence and nature of sexual harassment [43] and there was no significant relationship between education of women and incidence of sexual harassment [28]. There may be a need to standardize and categorize the nursing educational levels for nursing studies.

In addition, the other sociodemographic characteristics showed a significant association with women nurses work experience and exposure to sexual harassment. Women nurse with work experience less than 20 years (11.5 ± 8.7) was highly exposed to sexual harassment in their workplace higher than those with work experience of 20s or more years (11.5 ± 8.7). However, there was no difference in work experience in relation to the sexual harassment of Chinese nurses [26]. The difference could be the gender mix of participants in the previous review.

The second association with sexual harassment was the nurses working condition or occupational factor. Women nurse that assigned to work in a confined hospital units was exposed to the sexual harassment. For example, nurses working in closed units of hospitals became victims. In addition to this, nurses working in orthopedics, surgery, emergency, medical wards exposed them higher to sexual harassment. The incidence rate of sexual harassment was also higher in these units compared with working in the obstetrics and gynecology unit of hospital and working at a clinic. Our review is supported by studies that showed many workers such as women janitors, domestic care workers, hotel workers, agricultural workers, and often those working in isolated spaces reported higher rates of sexual harassment [44-46]. Another study supported our finding, the more privacy being accorded to a woman worker; the more likely she was harassed by the male colleagues because their co-workers were less likely to witness the harassment [28]. But, this systematic review disagrees with the meta-analysis showed no difference in sexual harassment among nurses working in hospital departments of China [26]. There might be due to uniform work discipline in the country and similar case handling in all facilities.

Our review indicated that the nurses working to shifts were associated with the sexual harassment against them. These assigned to work in both day and night shifts experienced sexual harassment than those working on day time only. This is similar with gender harassment that harassment was twice among women working at night shifts [42].

Findings from this systematic showed that the women nurse positive attitude to gender equality towards their patients and perceiving patients’ emotional demand were reported as a predictor of sexual harassment. In addition to this, women nurses perceiving greater emotional demands of patients were also associated with a greater likelihood of experiencing sexual harassment. This agrees with direct contact on patients’ body during injection procedure exposed the nurses to the sexual harassment in their workplace [3], and it was suggested that harassment may be tolerated by workers and employers in workplaces where an employee’s compensation may be directly tied to customer satisfaction or client service [16]. Women who were more knowledgeable about grieving procedure were more likely to interpret negative behaviors of men colleague and faced sexually harassing behaviors. The more feminine traits perceived by the worker, the more likely women were harassed according the previous study [28].

In the current systematic review, it was found that the women nurse perception of beautifulness and their good natural body structure was associated with the sexual harassment. Participants that were perceived to be beautiful were highly harassed and more exposed to the harassment than those with average beauty. It is supported by the study in which employees’ perceived good appearance was determinant of the prevalence and nature of sexual harassment [43]. Another previous study similarly showed that sexual harassment was found a significantly correlation with perceived physical attractiveness. In addition to this, women that dressed attractive wearing tight or revealing dress or mini-skirts were more likely sexually harassed [28]. Regarding women nurses’ body shape, these perceived to be with attractive body shape were highly harassed than obese and with less attractive body structure. This is congruent with nurses that had normal range of body mass index mostly get harassed [40].

Our finding revealed that there was an association with women nurses personality or interpersonal relationship and sexual harassment. Those who were friendly with, easily going with people, gentle, timid, not being fierce and without strict personality were highly exposed to the experience of sexual harassment. This shows agreement with a previous study personality of employees was related to the occurrence of sexual harassment in a workplace [43].

Conclusion

This systematic review confirms a number of factors associated with the sexual harassment towards women nurse. The factors related to sociodemographic characteristics of women nurses are being younger in age, single in marital status, without child, being assistant nurse in job title, and had less work experience. The women nurse working condition factors are working in closed units of hospital like working in orthopedic units, working in both day and night shifts, working for long duration of time of the workplaces and reside in rural area. The women nurse client concern factors such positive attitude to patients’ gender equality and fulfilling patients’ emotional care demand are also the factors associated with sexual harassment. The personal behaviors factors are nurses’ perception of own attractive body structure and beauty. The interpersonal related characteristic factors of women nurse are also being friendly with, not being strict and fierce, gentle in approach, going away with, and timid in behavior.

Therefore, health policymakers are recommended to developing a reproductive health guideline to protect young and newly deployed women nurse in hospitals from sexual harassment. It is recommended hospital managers to design fair working shift schedules and regular shift rotations, to minimize the women nurses’ longer stay at the workplace, and address sexual harassment in closed units of hospitals. It is recommended nurse managers to develop counseling and socialization programs on sexual harassment and reproductive health issues for young, less experienced, assistant nurses, reside in a rural area and for those working in closed units of hospitals. We suggest a nursing curriculum to incorporate life skills education on women nurses’ personal and interpersonal characteristics, decision-making skills for patients’ gender equality and patient emotional care demands handling in its content. Researchers are recommended to studying the relationship between women nurse educational status and sexual harassment, nurse responses to harassment and availability of sexual harassment reporting systems.

Limitations

This review cannot infer a causal relationship between the factors and sexual harassment. It covers cross-sectional studies published in English only.

Acknowledgment

We would like to acknowledge the Tehran University Medical Sciences International Campus for the provision of internet access and the librarians in the Tehran University Medical sciences, School of nursing and Midwifery for their help during the database search.

Source of Funding

There was no funding for designing and data collection, analysis, writing, and submission of the article for publication

Conflict of Interest

The authors declare that they have no competing interests with respect to the research, authorship, and publication of this article.

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