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High Reliability Healthcare

Observations and Lessons Learned on the Journey to High Reliability Health Care.

Sexual Harassment Between Health Care Workers and Safety Culture


By Esther Choo, MD, MPH,associate professor, Oregon Health & Science University; Ana Pujols McKee, MD, executive vice president & chief medical officer and Darilyn V.Moyer, MD, FACP, FIDSA, FRCP, executive vice president and CEO, American College of Physicians

A surgeon liked to tell stories and jokes of a sexual nature in the operating room (OR), and during surgery, would tease others in the room about their dating and sex life. He made frank comments about the figures of the women in the room and what he found attractive. 

Helena*, an OR nurse new to the facility, felt uncomfortable alone in the room with him. Whenever his teasing fell on her, she felt humiliated and silenced from sharing observations related to the patient’s case. She often thought that the discussion was distracting to the whole team, making them more focused on the surgeon’s banter rather than on the procedure itself. She complained several times to her immediate supervisor, who told her “that’s just his sense of humor.”

In another hospital, an older physician was notorious for groping and rubbing up against female residents and junior attendings in an outpatient clinic. The physician received multiple warnings from human resources over the years, but his behaviors continued to be tolerated. The clinic had a difficult time recruiting women to its staff and there was an extremely high turnover rate among women. This disrupted continuity of care for the patients in the clinic.

In a third institution, the male medical director of an ICU was dismissive and belittling to the nurse manager of the unit, often disregarding her suggestions about how to improve care on the unit and indicated both implicitly and explicitly that his opinion of her was very low. The manager felt demoralized and stopped bringing recommendations to improve care to the team, knowing they would be disparaged any way.

These cases demonstrate a spectrum of sexual harassment within health care. Sexual harassment includes:

  • gender harassment (sexist hostility and crude behavior)
  • unwanted sexual attention (unwelcome verbal or physical sexual advances)
  • sexual coercion (when favorable professional or educational treatment is conditioned on sexual activity). 

It is extremely common. Globally, 25% of nurses report experiencing sexual harassment; occurrence is higher in Australia, Canada, England and the United States (39%). Jagsi et al. reported in the January 2020 issue of Journal of Women’s Health that 82% of women in an academic medical setting reported at least one incident of sexual harassment in the past year.

Effect on Safe Patient Care
The delivery of safe health care is dependent on a robust safety culture. Establishing and maintaining a safe culture is the cornerstone of achieving high reliability within a health care organization. A high reliability health care organization (HRO) is one where leadership takes the responsibility of building a safe culture, which results in a workforce that feels free to speak up and identify risk without punitive retaliation.

Health care institutions have an obligation to:

  • review every aspect of their organizational structure
  • track metrics
  • institute procedures to ensure a zero tolerance for harassment and discrimination

Sexual harassment is a violation of safety culture; the same applies to harassment based on racial, ethnic or religious differences. Regardless of the factors that drive harassment, the impact to the patient remains the same and is tremendously costly to health care organizations. 

Leadership Responsibility
The vignettes above – all based on real events – exemplify the consequences, including:

  • worker burnout and attrition
  • lack of communication
  • distraction from clinical care
  • deterioration of the clinical team
  • lack of trust between coworkers
  • poor clinical outcomes
  • increased medicolegal risk. 

There is overwhelming data that a professionally satisfied and well health care workforce results in:

  • fewer medical errors
  • increased quality
  • less turnover
  • better outcomes and engagement from patients.

Leadership cannot assume that sexual harassment does not exist within their organization, but should proactively assess their workforce and respond in a timely manner to its occurrence.  This includes:

  • providing education and training
  • consistent efforts to project a cultural norm of respectful interpersonal interactions
  • protections for those who report harassment. 

Zero-tolerance policies and codes of conduct policies should be: 

  • established
  • visible
  • easily accessible to the whole community
  • applied consistently and to all members of the workforce equally. 

The dynamics of this approach requires a 24/7 commitment by leadership.

Sexual harassment is a problem we can no longer afford to ignore. We can eliminate sexual harassment from the workplace. It will require everyone’s attention and commitment, with the ultimate goal of improving patient safety.

*Name has been changed.

Ana McKee, MD, is the executive vice president and chief medical officer of The Joint Commission. 

Esther Choo, MD, MPH, is associate professor, Oregon Health & Science University.

Darilyn V.Moyer, MD, FACP, FIDSA, FRCP, is executive vice president and CEO, American College of Physicians.