Current status and factors associated with sexual harassment among operating room nurses: a multi-center cross-sectional study

This study was a multi-center cross-sectional study conducted at 20 medical centers from September 2023 to December 2023, and convenience sampling was used in consideration of the sensitivity of the research topic. The questionnaire was released to the operating room nursing staff of each hospital in a form of online survey (we chat two-dimensional code/link of mini program) to investigate the sexual harassment of operating room nurses in the past 12 months. In order to avoid duplication, the questionnaire was released with the setting that users could only fill in the questionnaire once. A total of 533 questionnaires were distributed in this study and 462 questionnaires were recovered with a recovery rate of 86.6%.

Inclusion criteria: ① Age ≥ 18 years old; ② Hospital operating room nursing workers; ③ Work or study in the operating room for at least one year. Exclusion criteria: ① Medical staff on leave; ② Have participated in similar researchers; ③Have taken maternity leave or sick leave in the past 12 months. Informed consent to participate was obtained from all of the participants in the study.

This study showed that the incidence of sexual harassment among operating room nurses was 63%, which was higher than that of other clinical nurses [1]. Forms of sexual harassment were dominated by gender harassment, mainly verbal harassment, including telling provocative stories, vulgar and obscene words, and offensive and rude words; followed by unwanted sexual attention and sexual coercion; in which male nurses suffered from sexual harassment more frequently than female nurses, which is in line with previous studies [35, 36]. Surgeons were the main harassers, especially married ones. This can be attributed to the close and prolonged interaction between nurses and doctors in surgical settings. Married individuals may more knowledgeable about sexuality due to their life experiences, hence they may not consider sexual jokes or physical contact as embarrassing or ashamed for others. Surgery after the closure of the body cavity is the main time of sexual harassment occurs. Following a tense operation, doctors subconsciously need a short psychological relaxation and often resort to verbal harassment like teasing or sharing lewd jokes with nurses as a way to get rid of the tension. So, hospital administrators should train their staff on knowledge related to sexual harassment so that perpetrators are aware of their wrongdoings and its consequences, victims’ awareness of anti-harassment is enhanced, and a professional environment with zero tolerance for sexual harassment is created. Sexual harassment can affect the working performance of operating room nurses, and causing distractions and errors [8‐10]. Enhance the professionalism and self-discipline of the surgical team. Even if the body cavity is closed during surgery, there are still many risk points in the surgery, such as bleeding, foreign body left behind, and anesthesia accidents, etc. Surgical participants should keep surgery with rigorous attitude to ensure the safety of the patients. The management and supervision of doctors should be strengthened and sexual harassment should be included in the outcome of doctors’ career assessment.

Disturbingly enough, these behaviors have gradually become normalized [12], and nurses become accustomed to sexual harassment with continued and repeated exposure to it; sexual harassment is integrated into the working environment of the operating room, forming an inclusive operating room culture.

The vast majority of victims employed passive coping strategies, similar to previous studies by [16, 30]. 90.4% of the victims in this study implicitly refused and changed the topic; 86.3% of the victims smiled, or used humor to diffuse the awkward situation. Especially when the abuser is a coworker, victims may respond negatively for fear of damage to their reputation and its potential aspect consequences [16]. Repeated exposure to sexual harassment can desensitize medical staff members and normalize such behavior in their daily work routines [37]; this may also explain the negative response. Only 31.6% regarded the harassing behavior as a joke and told themselves that it was not important; 45.4% of the victims behaved as if nothing happened, ignoring, forgetting, and tolerating it. It shows that sexual harassment is a problem for victims that cannot be ignored, and long-term exposure may evolve into a chronic stressor.

This study shows that 52.2% of the victims who will report to superior, while 47.8% kept silent, a higher reporting rate than in previous studies in China [38]. This may be due to the fact that this survey was conducted in Sichuan Province, China, where the husbands show a high degree of obedience and respect to their wives in family life, which is a symbol of men’s sense of responsibility and love of the family virtues. Since ancient times, traditional agriculture in Sichuan has not relied on men to provide a large amount of labor, and women’s labor has also produced considerable output; the economic value created by women in the family is equally substantial to that of men. As a result, women in Sichuan enjoy a higher social status in work and life than in other places, and are more vocal.

Further study of the reasons for maintaining silence revealed that it is primarily driven by concerns regarding friendship and interpersonal relationships with colleagues, as individuals aim to avoid causing conflicts; secondly, they thought that the harasser might not be subject to substantive punishment; thirdly, they were afraid of the negative consequences of reporting, such as oppression by authority and hindrance to their future; they were afraid that their reputation might be damaged and they would be criticized for “keeping a family shame in the public domain”; They feel that it does not matter and that it is harmless. These reasons are similar to previous study, in which the perpetrators of sexual harassment were primarily physicians [19]. Doctors are higher than nurses in terms of social status, education, and salary, or hold high positions [37], creating power pressure on nurses. At the same time, they are also afraid of destroying the friendly relationship with colleagues, causing unnecessary trouble and affecting their work and future [16]. Others believe that these behaviors are irrelevant or a waste of time to report, and that the perpetrator may not be punished accordingly [2, 15, 16]. Perhaps keeping silent for them is an expression of self-protection and avoidance of conflict, but acquiescence and tolerance can contribute to the harasser’s bad behavior.

In our study, the main reason to keep silence is they were concerns regarding friendship and interpersonal relationships with colleagues, as individuals aim to avoid causing conflicts. it may influenced by confucianism, traditional chinese culture emphasizes the value of harmony, and “harmony” is not only a means of dealing with conflicts and maintaining good interpersonal relationships, but also a motivating factor of collectivist culture, used to protect group cohesion [33]. Another reason is they were afraid that their reputation might be damaged and they would be criticized for “keeping a family shame in the public domain”. women concern for their reputation, and often choose to endure when they are humiliated by sexual harassment. Whether any harmony related to nobility or morality was essentially maintained remains to be examined. In some countries or regions where sexuality is conservative and women’s rights are not well developed, the same reason may exist [16], or it may be related to the lack of knowledge of sexual harassment among the group of nurses in the operating room, who do not know how to deal with sexual harassment, and therefore take passive measures to deal with it. Therefore, the improvement of the female protection system and the training of medical staff on sexual harassment are indispensable.

We found that there is a lack of management and proper handling of sexual harassment in healthcare organizations, only 39.2% of the hospitals in this study have a way or method to report sexual harassment, 30.7% of the hospitals have a department to deal with sexual harassment in the workplace, and 46.8% of the hospitals have a communication and discussion about psychological safety after sexual harassment. 49.4% of the leaders encourage nurses to report sexual harassment, 55.8% of the leaders will show concern for the victims, 56.3% of leaders take appropriate caring measures, and 48.5% of leaders listen to nurses about sexual harassment. Healthcare organization support and managerial attitudes are important influences on the occurrence of and response to sexual harassment [16].Song et al. [38] found that the main reasons for silence after experiencing sexual harassment were a lack of knowledge about the reporting pathway and related events, low priority given to healthcare workers, and lack of managerial response to the report.

Meanwhile, the operating room nurses in this study had insufficient legal knowledge about sexual harassment and weak awareness of their rights. 24.5% did not know how to protect their legal rights and interests, and 30.5 − 36.4% did not know that the perpetrators of sexual harassment would be dealt with by the law, and that the business unit should be punished and held responsible for the behavior. This, to some extent, encourages the bad behavior of harassers. Perhaps, improving the institutional setup and policy support, as well as training staff on sexual harassment can reduce the occurrence of sexual harassment in the operating room and its negative consequences.

Sexual harassment in this study had the most prominent impact on operating room nurses at work in the form of decreased quality and efficiency of work, decreased work engagement, and negative workplace stress experience. In addition, sexual harassment was associated with absenteeism and turnover [37], leading to poorer job performance and affecting the quality of healthcare services, patient life safety, and disease recovery [39]. This is followed by psychological anxiety, stigma, and fear; sleep disturbances, headaches, and nausea and vomiting; as well as reduced trust in the opposite sex and affected family life, consistent with previous studies [36, 40‐42]. Meanwhile, sexual harassment can deteriorate their relationship with their spouses, breed mistrust, and even lead to family breakup [39]. Thus, it can be seen that sexual harassment not only jeopardizes the physical and mental health of nurses, but also affects their family and social life.

According to American psychologist Herzberg’s two-factor theory of motivation, there are two factors of work motivation: Hygiene Factors and Incentive Factors. Among them, Hygiene Factors are related to the working environment and conditions of the employees, which can reduce their dissatisfaction and discomfort with their jobs. For example, providing good working conditions, safe environment and reasonable work load and maintaining good employee relations [43]. Work and physical and mental health interact with each other, and a healthy body and mind make a person present a good working condition, and vice versa. Negative physical and psychological consequences of sexual harassment further weaken their work performance. Therefore, providing a safe and comfortable practice environment for nurses in the operating room is necessary for surgical safety and the construction of a magnetic hospital.

Personality traits are important for sexual behavior and health. We found that individuals with agreeableness and openness personalities had 6.865 and 4.431 times higher likelihood, respectively, of experiencing sexual harassment compared to those with emotional stability personality traits. Neuroticism characterized by difficulty in balancing emotions of anxiety, hostility, repression, self-consciousness, impulsivity, which affect emotional stability. In contrast, the openness personality has traits such as imagination, aesthetics, emotional richness, dissimulation, creativity, and intelligence; and the agreeableness personality has traits such as trust, altruism, straightforwardness, dependence, humility, and empathy [44]; higher emotional value and comfortable and pleasant feelings can be obtained when spending time with people with these personalities, and they may be more favored by abusers. In addition, different personalities exhibit different sexual tensions, with neuroticism personalities being relatively conservative in terms of sexual topics and needs [45]; whereas openness personality traits have been associated with liberal sexual attitudes, and agreeableness personalities have been associated with sexual infidelity [44], both of which exhibit more tolerant and open sexual attitudes through internalization, and may therefore give the abuser an inch. Previous studies have mostly concluded that young and beautiful women are more likely to suffer sexually harassed [1, 2], but in a closed environment such as an operating room, where there is a uniform of hand-washing gowns, masks and hats, and less visual impact, the attraction of appearance and age to the harasser is not so absolute, and the role of personality factors is strengthened. Being comfortable with each other and having a good conversation is more likely to make the abuser want to get into trouble. Therefore, it is important to provide more care and assistance to people with agreeableness and openness personalities, and to teach them how to avoid and deal with sexual harassment. Such as not being alone in a room with a doctor, avoiding exposure to inappropriate remarks and behavior, and reporting any sexual harassment to the hospital.

Drinkers in this study were more likely to suffer sexual harassment, which is consistent with the study of Weldesenbet et al. [46]. In our study, it is mainly related to the geographic culture in which this study was conducted. Southwestern Sichuan Province is located in the Yangtze River Basin, which is the birthplace of Wuliangye, Luzhou Laojiao, Langjiu, and other alcoholic beverages, and has a strong alcohol culture. Wine is an important means of socialization and conversation, and those who can drink are more likely to be accosted or invited. However, this is only a phenomenon arising from the particular culture of the region, and further research is needed on the relationship between alcohol consumption and sexual harassment.

Previous Studies found that males are more likely to experience sexual harassment than females [8, 47], and there are also studies that show that females are more likely to experience sexual harassment [35, 48], the results of our study show that gender does not have a significant effect on sexual harassment behaviors, probably because of the small sample size of males that were included. However, the probability of men (80.5%) experiencing sexual harassment in this study was much higher than that of women (63.0%), and it is possible that the abusers think that men’s perceptions of sexual harassment were normalized, and even if the fact of sexual harassment existed, they were reluctant to define it as sexual harassment, and the emotional distress it caused them was minimal [7]. Moreover, there is insufficient legislation in China to protect men; in a patriarchal culture, their self-esteem also makes it difficult for them to publicize their experiences of sexual harassment. In the past, much attention has been paid to the sexual harassment of female nurses, who are seen as a vulnerable group and are more likely to experience emotional distress and physical problems [5], but more recently, research has begun to focus on cases of sexual harassment of male nurses [2], which has proven that the case should be treated equally by both genders, and that male nurses are also in need of appropriate support and protection.

Younger nurses (18–25 years old) in this study were more likely to experience sexual harassment than older nurses (> 45 years old), which is the same as previous studies [1, 8]; however, the difference is that those who are in love and married are more likely to experience sexual harassment than those who are single. It is possible that abusers think that married people are better able to tolerate and endure sexual harassment and then commit harassment. On the other hand, in Southwest China, young singles usually do not talk about sex in the workplace because they are more conservative than in the West and coastal areas of China, whereas romantically involved or married people have experienced sex and are more open to the idea of sex, and sexual harassment under certain circumstances will not lead to resentment or consequences.

Our study also found that the higher the level of social support, including family, friends, the hospital management system, and the attitude of leaders, the lower the probability of sexual harassment. Consistent with the study of Alhassan et al. [16]. The establishment of sexual harassment reporting mechanisms and responsible departments in hospitals, encouraging victims to report, and psychological communication and counseling on related safety issues may reduce the incidence of sexual harassment in the operating room. In addition, the attitude of bystanders is also very critical. Operating room work is a team that includes surgeons, anesthesiologists, instrument nurses, and visiting nurses in the operating room, and when sexual harassment occurs or is about to occur, if bystanders are able to help in a timely manner, they may be able to reduce or prevent the occurrence of sexual harassment and its negative impacts by changing the topic of conversation and resolving the embarrassment. Managers can promote an anti-sexual harassment team culture, conducting awareness-raising and training activities against sexual harassment at the same time.

This multicenter study was conducted to gain the prevalence of sexual harassment among operating room nurses in southern Sichuan, China, the forms of harassment, social support in hospitals, and the reasons for victims’ silence, as well as to explore related influencing factors. Moreover, the hospitals included in this study were all secondary or higher level hospitals, and the sexual harassment of nurses in operating rooms of community and township health centers was not explored, which affects the extrapolation of the findings. In addition, the way the retrospective questionnaire was self-reported, as well as the sensitivity of the topic, there was recall bias and reporting bias. For example, many people may be reluctant to admit that they have been sexually harassed; the fact that sexual harassment exists, but the victim does not perceive it as harassment due to a lack of knowledge, may affect the reporting of sexual harassment. Cross-sectional surveys can only describe the current situation and show that these factors are related to sexual harassment, but they cannot infer a causal relationship. Moreover, The sample size of this study is small, may limit the generalizability of the findings.Cross-sectional surveys can only provide a description of the status quo, suggesting that these factors are associated with sexual harassment, but unable to Infer the causal relationship between the two. convenience sampling could introduce selection bias, as the participants may not represent the broader population of operating room nurses. It is suggested that future studies may expand the scope of population and institutions, supplemented by qualitative research methods, to dig deeper into the factors related to sexual harassment in the operating room, such as the abuser’s psychological state and motivation, the way of coping with different personalities, and the reaction of the bystanders, so as to formulate the strategies of safety in the occupational environment.