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Psychological Impact of Work Place Harassment on the Nursing Community and Why We Must Firefight It

Submitted by on October 30, 2016 – 12:10 AM

no harassment conceptHarassment is defined as “any unwelcome sexual advance, request for sexual favors or other verbal or written communication or physical conduct of a sexual nature, or sexually demeaning attitudes, causing interference with work performance or creating an intimidating, hostile or offensive work environment, or the attempt to punish the complainant for refusal to comply with such a request or is made a condition for employment” (“The Protection Against Harassment of Women at the Workplace Act”, 2010).



Recently during winter clinical rotation, a student nurse observed that the attendant of her assigned patient was mistreating a new nursing female intern. On inquiring, she shared that the attendant was constantly asking for her contact number and on denying, she was verbally abused by him and tried to touch her.



Furthermore, the attendant was continuously starring at the novice intern nurse and pressing call bell unnecessarily. To avoid the situation, the intern nurse requested the student nurse to attend the call bell instead of her, but the attendant refused to talk to student nurse and pointed to her by saying “I want to talk to that staff”. She was looking very nervous and was not able to perform her tasks properly.



The student nurse asked her to report this issue to the hospital management, but she was too frightful and said “ The attendant  holds a higher position at government level and if I report it  I will get into trouble”. She took sick leave and went. In the last 4 days of clinical rotation, she was not seen in the hospital ward and when asked about her from other staff, the response was that she was on sick leave.



Despite the fact that the tertiary hospital had zero tolerance policy; the victimized staff could not report the issue to the hospital management. This was shocking to me that how can one work in such miserable environment,  witnessing this bitter truth which is hard to accept, but unfortunately it is the current situation of workplace especially for nurses. Therefore, I chose this issue to highlight the understanding, varying aspects, and consequences of workplace harassment towards nurses and possible preventive measures to develop a harassment free work environment.



In Pakistan, above 95 % of nurses are females and the nurse to patient proportion is 1:50,000, (Jafree et al. 2015) indicating a great shortage of nurses in the country. According to study by (Gul, 2008) there is a low public understanding about the profession of nursing that is an important factor impacting negatively on role and desirability of the noble profession of nursing in Pakistan (p. 14).




The major contributing factor is disrespectful behavior towards the nursing professionals. Pakistan is an Islamic country and Islam has certain boundaries for women, which is pointed out by (Gul, 2008) “Although Islam does not expressly prohibit the practice of nursing by females, it does emphasize modesty, which imposes certain restrictions on interactive behaviors, such as touching, with members of the opposite sex” (p. 6).



Thus, it can be inferred that involvement (body contact) of female nurses with the opposite gender is one of the key reasons for nursing profession to be considered inferior in Islamic countries. According to (Somani & Khowaja, 2012) Nurses are at higher risk for workplace harassment because of the type of tasks they perform, such as being involved in providing hygiene care to patients (i.e., bathing, cleaning body parts, etc.).



In our society, performing such tasks are considered as of inferior reputation, hence nurses, being disrespected and considered less worthy and becoming more prone to be harassed at workplace. Whereas, (Khan, Begum, & Shaheen, 2015)  adds that the reason of nurses being vulnerable to workplace harassment is the hierarchical structure of health care setting, where physicians have dominating positions, and nurses have low positions. Further reports according to a study in Pakistan, the rate of physical and verbal harassment of male physicians towards female nurses were 13.2 and 72 percent, respectively.



(Ali, 2010) defines that “Pakistani women generally go through three different levels of issues within SH (sexual harassment) process. Firstly, women endeavor to hide such issues  due to Islamic modesty and cultural traditions. Secondly, once they decide to take action there is a lack of redress at organizational and government level. Finally, once they report the issue they face victimization.” This relates to the clinical situation, that the intern-nurse might have had a fear of becoming a  victim if the issue was reported.



Workplace harassment is an emotionally distressing event for sufferers and it can have physical, psychological and economical impacts on the sufferer. The adverse effects of workplace harassment can result in poor job performance by nurses like “poor motivation and attention in performing duty, tolerance and consideration for work, which badly affect patients’ care” (Mojoyinola, 2008, p. 143).



Similarly, (Berry et al., 2012) finds in a study that thirty-three percent (33%) of nurses intended leaving their job, who reported bullying. Additionally, nurses were emotionally exhausted and took a day off because of not physical illness but to escape from psychological stress (p. 81). This holds true for the above-mentioned clinical scenario that the intern nurse could not perform her tasks on the assigned patient with proper attention and took sick leave to avoid that stressful situation.



(Mushtaq, Sultana, & Imtiaz, 2015) describes that due to harassment, victimized individuals develop a chronic stressor, which leads to severe physical and mental problems such as, anxiety, adjustment disorders, depression, stress, phobic, somatoform disorders, post-traumatic stress disorder, and suicidal ideations. Moreover, “the nurses who experience sexual harassment are expected to suffer from depression 3 – 8 times more than the women who were not harassed” (p. 675).



It is further stated that the constancy of depressive symptoms for long period develops depression and researches suggest that stressors create barriers to one’s physical and mental health (p. 678). However, (Naveed, Tharani, & Alwani, 2010) states that it is not only the individual who suffers but it also has a negative impact on the quality of service of the organization as well. This eventually decreases the efficacy of the employees due to feeling of insecurity at workplace (p. 223).



Integrating Theory and Strategies:

Change theory first identified by Lewin (1951) that consist of three stages: “Unfreezing, Moving, and Refreezing” (Mitchell, 2013). Later, Lippitt (1958) introduced his theory that is a revised form of Lewin’s Theory which comprises of “seven phases” for the process of change, which includes the following: “Diagnosing the problem, assessing the motivation and capacity for change, assessing the change agent’s motivation and resources, selecting progressive change objectives, choosing the appropriate role of the change agent, maintaining the change, Terminating the helping relationship” (Roussel, 2013, pp. 135-136). These phases of Lippitt’s theory help to better identify and effectively manage problems faced in workplace.



Phase 1: It is about diagnosing the problem. The nurse is defined as a change agent and should look for all the ramifications of the problem and takes the initiative by involving in policy making and top management roles to properly analyze the issue. As in the above scenario, the nurse did not fulfill her role of a changing agent, which negatively impacted on her job performance. It is the management’s responsibility to make sure that such cases be dealt promptly to ensure psychological and physical safety of employees.



Phase 2: Assessing the motivation and capacity for change. In this step, confidence of employees should be boost up by top management roles so that they rise against any mistreatment they face. Somani & Khowaja, (2012) stated that mostly workplace harassment is not reported by victim (nurse) due to fear of social stigma (p. 151). This shows a lack of motivation by the managers or policymakers towards employees resulting in inability of victims to report the incident.



Similarly, (Malik, Malik, Qureshi, & Atta, 2014) suggests, that by initiating and implementing policies, harassment training sessions, and actions to provide a safe and smooth work environment for in-training nurses.



Phase 3: Third stage is about “assessing the change agent’s motivation and resources”; this talks about collaboration among workers. Roussel (2013) defines two types of change agent, such as, external and internal to the division or organization (p. 136). For internal change agent, although it is the duty of management or leaders to take the lead but nurses and other health care providers are equally accountable to report the incident so that the harasser realizes the unacceptable deeds and not to repeat such behavior.Whereas, external change agents would be legislations and policies against workplace harassment developed by government.


Phase 4: The fourth step is selecting progressive change objectives. Strategies are developed and employees are allocated with certain roles and responsibilities. For enduring impacts, objectives should be attainable and realistic.



Phase 5: This phase is defines about selecting the suitable role for the change agent. Organization’s management should develop a proper set of guidelines or policy that must be strictly followed. Shiwani & Elenin (2010) elaborate that “Department of health in Pakistan might have an existing up to date policy, but is not accessible to public and personal communication has revealed that many of government employees have never even heard of such a policy”.



Therefore, the reason behind workplace harassment is either unavailability of a set of guidelines or a lack  of implementation of policy. Somani & Khowaja (2012) states “Some health care settings in Pakistan, such as The Aga Khan University Hospital (AKUH) follow a  zero tolerance policy with respect to workplace violence; and according to the policy, the hospital does not tolerate the violent behavior of patients, family members, visitors, and employees” (p. 150).



Phase 6: Maintaining the change. The sustainability of the change that we want to bring solely depends on the implementation and adherence of self to the developed policy, which is challenging but of utmost importance. Somani and Khowaja (2010) states “In some health care settings, policies regarding workplace violence do exist but only for documentation and files purposes and as practical implementation is absent; neither the victims nor the perpetrators are aware about these policies” (p. 150).



In our case scenario, inability to report the incidence was due to fear of being humiliated and harassed by attendant at later time, as he was holding a higher position in government and probably the staff was unaware or not properly educated about the impact of “zero tolerance” policy. The management should educate every employee about effects of policy and to make sure that it must be applicable to all, irrespective of the status of perpetrator.




Phase 7: The last phase is terminating the helping relationship, which states about withdrawing the change agent at specified point of time but “the change agent will remain available for advice and reinforcement” (Roussel, 2013, p. 136).




In health care settings, Harassment towards nurses has become a serious issue. This not only effects on physical, psychological health of caregiver but also hinders the quality of care provided to the patient. The reason for workplace harassment is that it goes unreported due to any reason, resulting in increasing incidences.



Literature review suggests that for sustainability of change and maintaining “zero tolerance” policy, those who are in role or management should adopt a leadership style. Moreover, it is every individual’s responsibility to report any mistreatment in workplace, so that the management can effectively deal with the problem. Nurses in collaboration with other employees, such as, hospital management, policy makers develop strategies to change the atmosphere of health care into a harassment free work environment.


Frequent workplace harassment related awareness sessions should be conducted. Policy makers and/or leaders should develop a “zero tolerance” policy against Harassment and should empower and encourage nurses or employees to report such incidences. Furthermore, strict actions must be taken against the reported issue.




  1. Ali F. (2010). Sexual harassment in Pakistan: An invisible crime. SEPLAA News.       invisible-crime/
  2. Berry, P.A., Gillespie, Gordon, L., Gates, D., & Schafer, J. (2012). Novice nurse productivity       following workplace bullying. Journal of Nursing Scholarship, 44(1), 80–87.   doi:10.1111/j.1547–5069.2011.01436.x
  3. Gul, R. (2008). The Image of Nursing from Nurses’ and Non-Nurses’ Perspective in Pakistan.      First Independent Nursing Journal Of Pakistan, 1(2), 4-17.
  4. Jafree, S., Zakar, R., Zakar, M., & Fischer, F. (2016). Nurse perceptions of organizational culture            and its         association with the culture of error reporting: a case of public sector hospitals in   Pakistan. BMC Health Services Research, 16(1).    1252-y
  5. Khan, N., Begum, S., & Shaheen, A. (2015). Sexual Harassment against Staff and Student          Nurses in Tertiary Care Hospitals Peshawar K.P. Pakistan, 4(1), 285-292.
  6. Malik, N., Malik, S., Qureshi, N., & Atta, M. (2014). Sexual Harassment as Predictor of Low         Self Esteem and Job Satisfaction among In-Training Nurses. FWU Journal Of Social   Sciences, 8(2), 107-116.
  7. Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing         Management, 20(1), 32-37.
  8. Mojoyinola, J. (2008). Effects of Job Stress on Health, Personal and Work Behaviour of Nurses in Public Hospitals in Ibadan Metropolis, Nigeria. Ethno-Med, 2(2), 143-148.
  9. Mushtaq, M., Sultana, S., & Imtiaz, I. (2015). The Trauma of Sexual Harassment and its Mental   Health             Consequences Among Nurses. Journal Of College Of Physician And Surgeons    Pakistan, 25(9),             675-679.
  10. Naveed, A., Tharani, A., & Alwani, N. (2010). Sexual harassment at work place: Are you safe?    Journal of Ayub Medical College, 22(3), 222-224.
  11. Roussel, L. (2013). Management and leadership for nurse administrators. Burlington, MA:            Jones & Bartlett Learning.
  12. Shiwani, M. H., & Elenin, H. (2010). Bullying and harassment at workplace: Are we aware? J       Pak Med Assoc, 60(7), 516-517.
  13. Somani, R., & Khowaja, K. (2012). Workplace violence towards nurses: A reality from the            Pakistani context. JNEP, 2(3).
  14. The Protection Against Harassment of Women at the Workplace Act. (2010). International           Labour Organization. Retrieved from   …/PAK92235.pdf



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