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The Spiritual Impact of Workplace Sexual Harassment and Bullying on Nurses

Stacey Lamar, New York Medical College, New York, USA Deborah Viola, Center for Long Term Care Research & Policy, SHSP, New York, USA

Abstract: Registered nurses constitute the largest proportion of the healthcare workforce in the United States. According to the department of labor, registered nurses hold more than 2.6 million jobs. 92.1% of them are female. Studies indicate that approximately 17 of every 20 nurses have experienced some form of workplace sexual harassment. Sexual harassment is defined by the federal government as a violation of Title VII of the Civil Rights Act. A hostile work environment involves unwelcome sexual conduct, threatening or humiliating behavior that may interfere with work performance. Bullying involves repeatedly poor treatment of a person that can include abuse of power and degradation. This paper describes findings from a focus group of nurses that experienced sexual harassment and/or bullying. Several issues were explored, including childhood and dating experiences, marital status, and ability to communicate with spouse/partners, as well as the spiritual impact the participants described. Spirituality is recognized as the deeply personal values, beliefs, and perceptions that guide behavior. Spiritu- ality is influenced early in childhood and is linked to physical and mental health status. A better understanding of the influence of sexual harassment and/or bullying on an individual’s spiritual orientation could influence personnel policies, sexual harassment training, and counseling programs.

Keywords: Spirituality, Workplace Sexual Harassment, Bullying, Registered Nurses

INTRODUCTION

D iscussions of sexual harassment and bullying in female dominated occupations span several decades. In the United States, federal legislation to address this problem was first introduced as part of the Civil Rights Act in the 1960’s. Title VII of this important legislation identified sexual harassment as a form of gender discrimination in the work environment. The current definitions have evolved since then to include all

unwanted physical or verbal advances of a sexual nature which should not happen in the workplace. This includes bullying and the repeated mistreatment related to abuse of power and intimidation, all of which can contribute to a hostile work environment if left unresolved. Perhaps more importantly, clear guidelines were also established for employers redefining their respons- ibilities to protect employees. Despite these guidelines, reports of sexual harassment and bullying continue to rise in female

dominated professions such as waitressing and nursing. As many as 17 of 20 nurses report being victimized by some form of harassing behavior (Valente & Bullough, 2004). Persistent and growing reports of unwanted behavior by colleagues and supervisors are an obvious threat to the integrity of individuals and reflect negatively upon the profession as a whole. Registered nurses remain the largest proportion of the health care workforce; approximately 92% are female (U.S. Department of Labor, 2012). Even as more male nurses enter the workforce, the profession

The International Journal of Health, Wellness and Society Volume 2, Issue 2, 2013, http://healthandsociety.com/, ISSN 2156-8960 © Common Ground, Stacey Lamar, Deborah Viola, All Rights Reserved, Permissions: [email protected]

continues to be victimized; surprisingly, complaints by male nurses are beginning to be identified as well. It may seem counterintuitive that sexual harassment and bullying is so pervasive in what is

understood to be a healing and caring profession. By contrast, society has an expectation that workplace harassment is part of the job description for a waitress. This expectation is firmly rooted in the stereotypes commonly portrayed in the media and inures us to its inappropriateness. Waitressing is not viewed as a professional career. It is a job for a struggling, young, aspiring actress or working class woman, undereducated, needing to make ends meet. Harassment and tips become virtually synonymous; in contrast, nursing is a career. A nurse is educated, profes- sionally trained, working in an environment among other trained professionals. Although harassment within nursing is more difficult to conceptualize, it remains pervasive. A survey by Kinard and Little (2002) tracked sexual harassment filings from nurses reported to the U.S. Equal Employment Opportunity Commission (EEOC) over a ten year period. Astonishingly, they found a 52% increase over this time period, a number which is believed to be an underes- timate. Thousands of cases remain unreported by nursing personnel for a multitude of reasons, including embarrassment, fear of losing one’s job, and the victim’s belief that somehow she is at fault. The EEOC (2012) received reports of more than 11,000 complaints of sexual harassment in

2011. Of the complaints filed, 16.3% were by males. Within the nursing profession, approxim- ately half of female nurses report being exposed to some form of harassing behavior and ap- proximately one-third of male nurses report the same (Fiedler & Hamby, 1994). Not all nurses become victims. Other variables exist that may contribute to one person in the same workplace being more vulnerable to victimization than another. An impressively large body of international research proves that people who report workplace harassment or victimization may also have experienced some form of victimization in childhood. Important social and economic determ- inants that may contribute to adult victimization include culture, gender, religion, income, education, socioeconomic status of the abuser, and prior relationships. A review of the nursing literature has identified physical and emotional symptoms associated

with harassment. In addition, nursing studies have identified problems in recruitment and re- tention as a consequence of losing staff due to the effects of working in a hostile and stressful environment. These are valuable studies that are helping to address work place issues relevant to the profession. Yet, the impact of gender based discriminatory behaviors on a nurse’s spir- itual being have not been studied. This suggests that policies addressing the individual’s need to heal and recover, and the employer’s need to provide appropriate, pro-active education and counseling, are not being fully considered. The purpose of this exploratory, pilot study is to test a mixed-methods research model to

determine the impact of harassment on a small group of nurses with a focus on spiritual well- being in addition to the usual determinants of victimization. We combine results from a likert scale survey, adapted from the Sexual Experiences Questionnaire (Fitzgerald, Gelfand, & Drasgow, 1995), of a group of registered nurses who have experienced sexual harassment or have been victims of bullying. Open ended questions were used to explore spiritual beliefs of these nurses. Our findings suggest that participants shared similar prior experiences with respect to difficult parental and personal relationships and this may place them at a higher risk of adult victimization. However, for those who spoke to a stronger sense of self through either religious or spiritual guidance, there seemed to be lower levels of personal blame. Our findings also suggest and support that there remains a significant under-reporting of harassment and bullying.

Background

Legal definitions of sexual harassment have evolved for more than four decades, but the under- standing that it is unlawful to harass another person because of their gender has remained

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constant. Sexually harassing behavior includes unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature that interferes with work performance (U.S. EEOC, 2012). Sexual harassment is the umbrella for which two sub-categories, quid pro quo and hostile work environment, are classified. Quid pro quo occurs in the super- visor-employee relationship, when submitting to or rejecting advances will directly affect em- ployment decisions of the victim, e.g. if the victim complies with sexual advances she will receive a raise or promotion. A hostile work environment is a workplace where an employee is being intimidated, ridiculed, or mistreated because of her gender, race, religion, or national origin. Workplace bullying is a form of hostile work environment. Despite the development of legal definitions that validate the existence of these oppressive

behaviors, individual perception continues to dilute what constitutes sexually harassing or bullying behavior. Huebner (2008) discusses how definitions of sexual harassment in society rely largely on individual perception and pre-conceived social and legal categories as a means of labeling. Thus, an individual who witnesses a form of legally defined sexual harassment may not identify it as such if the colleague experiencing the harassment does not appear to react in a manner that supports the legal definition. This reliance on individual interpretation of inap- propriate behaviors often conflicts with legal definitions and as a result it is not possible to capture all potential variations of sexually harassing behaviors. Occupations that are primarily female are more likely to report sexually harassing behaviors

than male dominated ones, especially when the woman is perceived as being more passive, nurturing, or a sexual object (Fiedler & Hamby, 2000). These social and culture stereotypes can increase the risk of victimization. Sex role spillover theory maintains that sexual harassment is more prevalent in jobs that are commonly seen through this stereotypical lens (Huebner, 2008). Studies conducted across different social disciplines support a historical view that women in work roles still viewed as more submissive or sexually appealing are challenged by the neg- ative effects of ongoing, sexually, harassing behaviors (Bronner, Peretz, & Ehrenfeld, 2003; Fiedler & Hamby, 2000; Gunnardsdottir, Sveinsdottir, Bernburg, Fridriksdottir, & Tomasson, 2006; Gutek & Cohen, 1987; Huebner, 2008). Examples of these occupations include waitresses, flight attendants, teachers, dental hygienists, and nurses. As violence against women escalates in society, awareness grows as to the significance of this

public health problem and what determinants may contribute to the rise in women being sub- jected to such behaviors in the workplace. As young girls, early forms of sexually defining be- havior begin. Berman and colleagues (2000) discuss the “plight of the girl child” as they identify common behaviors within society that may contribute to female vulnerability. Assump- tions included in this research are the understanding that girls and women are socialized to expect violence in their lives; therefore violence becomes “normalized” behavior. They further posit that violence can be overt or subtle and that girls from all socioeconomic backgrounds are vulnerable. Findings from this research include the belief that sexually harassing behaviors are pervasive among young girls and are not being addressed properly at present. Siegel and Williams (2001) explore certain situational determinants that may be links for

child abuse survivors who are placed back in environments that put them at a high risk for being re-victimized as adults. Learned behavior theory asserts that women become submissive as a result of early childhood development. Houle and colleagues (2011), in their review of stress theory as it relates to development of depressive symptoms in victims, acknowledge in- creased vulnerability in some groups as a result of early life harassment. They further posit that “early targets are more likely than nontargets to be targeted again later in life.” Thus, submissive conditioning translates into a lower self-esteem and places them at a higher risk of abuse by men. Learned behavior such as witnessing violence in childhood relationships and an unstable family life may also contribute to this problem. Siegel and Williams (2001) suggest that the relationship between childhood abuse and adult victimization may be more complex than pre- viously thought. Women who report sexual abuse in childhood and adolescence, “double vic-

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tims,” were at an increased risk of adult victimization. Double victims were significantly more likely to report adverse relationships with their mothers which may have included physical abuse, an absent mother due to incarceration, or inconsistent parenting. Childhood living conditions and childhood adversities are associated with increased psychological distress in adulthood (von Rueden, Gosch, Rajmil, Bisegger, Ravens-Sieberer, & the European KIDSCREEN group, 2006). Culture and ethnicity are also contributors to adult female victimization. Within certain

cultures, women are more willing to accept or normalize sexually inappropriate behavior because their culture gives men permission to exercise control over their behavior. Olavarrieta and Sotelo (1996) compare differences in perception of sexually inappropriate behaviors between Mexican-American women and Anglo-American women. In their study, Mexican-American women view fewer types of behavior as abusive and have a more tolerant attitude than their Anglo-American counterparts. Within the workplace, sexual harassment theory remains more limited to organizational

structure and hierarchy (Menard, Nagayama Hall, Phung, Gherbrial & Martin, 2003). Institu- tions adopt policies based on federal guidelines as a means of prevention within their organiz- ation, but these guidelines are limited in scope and efficacy. Fitzgerald, Gelfand, and Drasgow (1995) conducted research to develop a conceptual framework to address workplace sexual harassment. This research led to the introduction of the Sexual Experiences Questionnaire (SEQ), a self-reporting instrument that allows researchers to gain insight of individual experiences in a psychometrically traditional format. The SEQ has been utilized many times since its incep- tion. It has also been revised on occasion by the developers as a means to measure harassment within a specific group of harassed women (Fitzgerald, Craig, Drasgow, and Waldo, 1999). The significant contribution of the SEQ by its authors has provided a tested and reliable method for conducting research in this area. Sexual harassment and bullying remain problematic in nursing. While the American Nurses

Association (ANA, 2012) maintains a formal, written policy regarding sexually harassing beha- vior, many nurses choose not to report their experiences. Although the nurse’s role has changed over time, the perception of the nurse as the nurturing and caring woman may contribute to the increase in workplace mistreatment. In a more homogenous, female workforce, sexually harassing behaviors may be viewed or labeled in a more consistent manner, but the nursing profession is culturally diverse. Thus, social-ethno-cultural variety within the nursing profession may be partially responsible for the significant amount of unreported cases. Ironically, nurses may be “doubly oppressed” since they are socialized as both nurses and women (Roberts, De- marco, & Griffin, 2009). Sexual harassment at work disrupts the ability to concentrate and compromises the safety

of patient care and satisfaction (Valente and Bullough, 2004). Examples of compromised safety include the nurse’s decreased ability to concentrate, which may contribute to her giving the wrong medication to a patient. Left unaddressed or unresolved, litigation and subsequent fin- ancial damages may be levied (Fiesta, 1999). Distractions can also lead to decreased workplace effectiveness, frustration, decreased morale, high absenteeism, and higher rates of attrition (Hamlin & Hoffman, 2002). Written policies that speak strongly against this behavior are a first step in the prevention process. However, victims often use terms other than “harassment” to label inappropriate behavior (Madison & Minichiello, 2000). Therefore, written policies and codes of conduct left unsupported by continuous education programs will not be effective (Broome & William-Evans, 2011; Hamlin & Hoffman, 2002; Libbus & Bowman, 1994). Numerous studies have researched the physiologic and psychological impact that sexual

harassment and bullying have on the nurse and its impact on patient care. Broome and William- Evans (2011) discuss the multitude of problems that may result in nursing from sexual harass- ment. Physiologic and psychological conditions may include eating disorders, headaches, fatigue, angina, as well as cognitive and depressive symptoms. However, the possible importance of

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her spirituality remains unexplored. Burkhardt (1994) describes spirituality as an essential component of the human condition and an important factor in health. Spiritual assessment in- vestigates a person’s denomination, beliefs, or spiritual practice. Moberg (2002) discusses the significant role spirituality plays in health and illness. He supports the growing consensus that human spirituality is “an ontologically existent or real phenomenon, in contrast to an earlier but still not rare positivistic assumption that it is merely a figment of folklore, myth, or collective imagination.” Wills (2007) notes that the “complex process of health has, until recently, been understood devoid of a spiritual component.” She identifies spiritual self as central to health and well-being. Therefore, further exploration of the spiritual impact of sexual harassment and bullying, utilizing a holistic approach, could help in improving prevention and education strategies used in the workplace.

Methods

This exploratory, pilot study utilized a mixed-methods research model to examine the associ- ations between childhood experiences, marital status, religious or spiritual beliefs, and workplace environment as they may relate to the harassing behaviors reported by nurses. The authors designed the Spiritual Impact of Workplace Sexual Harassment and Bullying on Registered Nurses Questionnaire (SIWSHB-RNQ) to explore the impact of this behavior on the human spirit (Table 1). This questionnaire is adapted from the Sexual Experience Questionnaire (Fitzgerald, Magley, Drasgow, & Waldo, 1999) which served as a framework in developing questions appropriate to harassment experiences within nursing practice. The purpose of this study is to identify trends between the participants’ past experiences and current experiences as they relate to the sexual harassment or bullying reported. Additionally, this study serves to identify trends in religious or spiritual beliefs of the participants and if their personal belief system was either harmed or served as a source of strength during the time of workplace stress or after. This pilot study does not fit criteria requiring institutional review and is thereby exempt. Seven registered nurses were recruited from the northeast region of New York State. Criteria

for inclusion in this pilot study included:

1. Participant must be a licensed registered nurse. 2. Participant must have experienced sexual harassment or bullying while working as a re-

gistered nurse.

Each participant was screened by telephone prior to inclusion in this study to confirm the eli- gibility requirements. Consents to participate were reviewed and signed by each participant and the survey responses were not identified. The questionnaire contains four sections (Table 1): section one covers standard demographic questions including age, marital status, gender; section two includes a 26 question likert-scale survey of in depth experience with sexual harass- ment or bullying; section three includes a 26 question likert-scale survey of participant’s child- hood experiences; section four includes open-ended questions that provide additional information related to sections two and three. A five point likert scale was used representing the following responses: strongly disagree, disagree, neutral, agree, and strongly agree. Descriptive statistics were calculated for likert-scale questions. Open-ended questions were

reviewed for similarities in participant responses. The use of quantitative and qualitative research methods enhanced the meaning of this study by allowing the participants to provide more de- tailed information regarding their experiences that might have otherwise been missed with the use of only the likert-scale method.

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Results

Seven registered nurses (6 female, 1 male, all white) participated in the Spiritual Impact of Workplace Sexual Harassment and Bullying on Registered Nurses Questionnaire (SI- WSHB-RNQ). Respondent demographics are reported in Table 2.

Participants were asked about sexual harassment and bullying they experienced within the work environment. Section 2 questions and responses are reported in Table 3. Participants identified the gender of the harasser as male (57%), female (14%), and harassment by both genders (29%). Section 3 of this questionnaire investigated the participant’s childhood, relation- ship with parents, including any reported abuse during childhood (Table 4). Of the 7 participants, 100% report that their parents were married at the time of their birth; however 3 reported their parents divorced during their childhood (43%). In addition, each participant responded that prayer positively impacted their lives.

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Section 4 consists of open-ended questions that provided an opportunity for each participant to describe more completely their personal experiences and expand upon specific questions from sections 2 and 3. This allowed for more detail, including title/position of the harasser, why the participants did or did not report abusive behavior, specifics regarding childhood abuse and how participants perceived their parents’ functioning during childhood. It was in this section that each participant was asked why they chose nursing as a career; 3 out of 7 (43%) responded that they wanted to help others or be of service to others. It was through this exploratory process that each participant reported that sexually fueled

conversations were a regular day to day experience in the work environment. Of the nurses who experienced sexual advances, they reported this was primarily by physicians. Of the parti- cipants that experienced inappropriate behavior by a nurse, they reported intimidation and threatening behavior that made them feel powerless. They further reported that the nurses who behaved in an intimidating or bullying manner were nurses in leadership positions. Six parti- cipants (86%) reported some form of childhood abuse that was emotional, physical, or sexual. Four of 7 participants (57%) strongly disagree that their mother was an excellent role model. Further exploration of this question revealed similarities in childhood experiences including feeling manipulated by and distrustful of their mothers. All 7 participants (100%) recognize prayer as helpful in their lives, and each stated they turned to prayer during stressful times in their lives. Five out of 7 (71%) participants do not blame themselves for the inappropriate actions that occurred during work hours; one participant remained neutral. One participant did report self-blame; this same participant also reported sexual abuse as an adolescent and expressed feelings of guilt and self-blame toward that circumstance. This group of participants reported continued concerns about the potential for sexual harass-

ment as a result of the physician-nurse relationship. They also reported concerns of senior nursing staff being more abusive to junior nursing staff and expressed that these female nurses in positions of authority often intimidate and make the environment uncomfortable to be in. Six out of 7 participants (86%) did not report the harassing or abusive behavior to anyone in the healthcare organization. They maintained silence for fear of making the situation worse. They coped by attempting to avoid the person to the extent possible. One nurse did report harassment by a female supervisor and stated that “she then became the target of retaliation by her nurse supervisor and other nurses.” She spoke about her feelings of intimidation and distress she endured for more than fourteen months before she left this job. Of the 7 participants,

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this was the only nurse who reported a loving and abuse-free childhood. This nurse also described her childhood as “being raised with instinct to fight and overcome.” She did not report self- blame for the bullying she endured and she also reported a strong religious or spiritual found- ation in childhood and at present. The majority of participants experienced parental divorce during their childhoods. Each

participant reported some form of abuse during their childhood with 4 out 7 (57%) identifying punishment including physical contact, 5 out of 7 (71%) reporting emotional abuse, and 3 out of 7 (43%) reporting sexual abuse during their childhood or adolescence. Four out of 7 (57%) participants reported mothers that were poor role models and open-ended questioning suggested that the common thread between the mothers was they were emotionally hurtful to their children, erratic, and manipulative during childhood and adolescence. Four out of 7 (57%) participants reported a strong religious or spiritual childhood and 5 out of 7 (71%) reported that they maintain a strong religious or spiritual foundation presently. Interestingly, 5 out of 7 (71%) of these participants view religion and spirituality as different concepts and in further exploration they stated their childhoods were more traditionally religious.

Conclusion

This pilot study serves as an exploratory study addressing the need for further research to de- termine the spiritual impact that harassment and bullying have on a victim. Additionally, this information is intended to improve the current strategies being utilized in the workplace to prevent this behavior and facilitate treatment of victims. Limitations of this study include the sample size and homogeneity of the group. Although this is a small, exploratory study and results are not presented as statistically significant, it does provide an understanding of potential similarities among nursing victims and the opportunity to pilot and modify the survey instrument before expanding to a larger sample. Within this focus group, the overwhelming majority clearly indicate that sexually offensive

or crude remarks were commonplace in the nurse’s workplace. As expected, these advances and remarks were not welcomed. Respondents did report that they would be judged or may make the matter worse if they did not comply with the behavior at the moment. Therefore, they remained silent. The majority of this group reported feeling embarrassed by sexually inap- propriate behavior to which they were exposed, but unable to say. One participant reported that advances were made toward her to have a sexual relationship without consent. The majority of sexually inappropriate behavior was reported to be by a male physician, while the aggressive or bullying behavior was reported to be by a female nurse in a higher ranking position than the participant. The male nurse participant of this study reported that aggressive and hostile behavior toward him did not come from a physician or nursing staff; rather he was subjected to inappropriate behavior by male correction officers who brought prisoners to the infirmary. He further described that he felt that these males in that role did not seem to respect a male nurse and the correction officers sometime acted like the nurse was not masculine because of his occupational choice. Regardless of the perpetrator or the act, nurses are working in an environment that presents

the potential of several hostile challenges; sexual harassment by a higher ranking supervisor, intimidation or bullying from a higher ranking nurse colleague or intimidation and bullying by a colleague. This creates potential for tremendous distraction and discomfort for the nurse trying to remain focused in an environment that is fueled by inappropriately placed sexual energy and aggression. Only one nurse chose to report the inappropriate behavior to which she was subjected; she subsequently felt ostracized by speaking against a supervisor and never felt sup- ported in the effort to investigate the truth by her colleagues or hierarchy. She left this job after more than a year of trying to cope and credits her faith with overcoming this challenge.

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As sexual harassment and bullying continue to be widespread, it is equally important to focus on policies that encourage victims to report abuse as it is to improve upon current practices and policies to teach employees about the seriousness and inappropriateness of these behaviors. Employers need to provide for adequate support and counseling which includes a focus on the physiologic, psychological, and spiritual well-being of victims. Nurses are trained to practice within a holistic framework of patient care; the nurse as victim should be treated similarly.

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ABOUT THE AUTHORS

Stacey Lamar: Stacey Lamar, CNM, LM, MA, DrPH(c) is a holistic women’s health provider and consultant, as well as Clinical Professor at the College of New Rochelle, School of Nursing. As a Certified Nurse Midwife, Ms. Lamar has extensive clinical expertise in women’s health issues and owns and operates a holistic private practice, The Willow’s Source, in the Hudson Valley, NY. Ms. Lamar is a DrPH(c) in the School of Health Sciences and Practice at New York Medical College. Her research interest involves the study of the impact of spirituality as it affects health and well-being within the social sciences. Ms. Lamar’s doctoral work focuses on the complex connection of spirit as it pertains to health and illness. This chapter is part of a larger dissertation research.

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Dr. Deborah Viola: Deborah Viola, PhD, is Associate Professor and Associate Director, Doc- toral Program, in the Department of Health Policy & Management at the School of Health Sciences and Practice at New York Medical College, where she also serves as a research scholar at the Center for Long Term Care Research & Policy. Dr. Viola is an economist whose current research includes the effects of home-delivered meals programs among frail, isolated NYC residents; a study of the relationship between income support programs and health among children and communities; the development of medical residency training that emphasizes the non-medical determinants of health; and the long term care needs of children with intellectual and developmental disabilities. Dr. Viola sits on many community boards, including the Bergen County Board of Social Services, where she is the Secretary and Treasurer. She earned a PhD in economics from the Graduate School at the City University of New York as a Robert E. Gilleece fellow.

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