Experiences of student and practicing physical therapists with inappropriate patient sexual behavior.

Key Words: Physical therapy profession, professional issues; Professional-patientrelations, Sex behavior, Sex offenses, Sexual harassment.

Sexual harassment has been recognized as an important and serious issue affecting many individuals, particularly women,[1] both in academia[2,3] and in the workplace.[4,5] There has been some research indicating that sexual harassment occurs at a relatively high rate in health care settings and that a large proportion of this harassment is in the form of inappropriate patient sexual behavior (IPSB) toward nurses[6-8] and other health care workers.[9] As part of the health care team, physical therapists may encounter this type of behavior frequently, yet no data exist regarding how widespread IPSB is in physical therapy.

The Equal Employment Opportunity Commission (EEOC) has defined sexual barassment as "unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature."[10(p33)] Although there has been some debate as to what constitutes sexual harassment, recent definitions have included the following range of behaviors: forced physical advances; sexual violence; sexually abusive or degrading language; offensive physical touching; and more subtle seductive behaviors such as innuendos, sexist remarks, leering and ogling looks, and persistent invitations or solicitations.[6,9,11,12]

It is believed by many social scientists that status and power are important for understanding the roots of the problem of sexual harassment.[13] Hotelling[14] has identified two types of harassment. "Quid pro quo" harassment occurs when a superior manipulates a nonsuperior by offering rewards, such as job promotion, in return for sexual favors, or by threatening punishment if the nonsuperior does not comply. "Contrapower" harassment occurs when a nonsuperior directs inappropriate sexual behaviors toward a co-worker, without implied or stated threat, resulting in a hostile environment. Benson[15] has argued that, due to "status incongruence" or status discrepancy (ie, low female status and high health professional status), men who sexually harass women may not perceive achieved status as important. Employment status may not necessarily give health professionals more power than their patients, because the patients may still lack power due to their gender. There have been far fewer studies of harassment by nonsuperiors, but there is evidence that this hidden form of sexual harassment is often unrecognized by the general public.[6]

The first studies concerning sexual harassment[12,16] largely sought to identify the prevalence of the problem for women in the workplace and were not specific to health care settings. In a qualitative survey of staff of an extended care unit for aged men, Szasz[9] found that incidents of a sexual]al nature occurred daily and almost 90% of staff had experienced some form of IPSB. In 1987, Grieco[8] reported on the scope and nature of sexual harassment in a survey of 496 state-licensed nurses in Missouri. He found that 76% of the respondents had experienced sexual harassment in their workplace. Patients as opposed to co-workers and supervisors were cited as responsible for the more severe harassment and as most often the perpetrators of harassment.

Many have speculated on the reasons for IPSB in health care settings. For example, IPSB has been attributed to medication side effects, organic brain syndromes, impotent men overcompensating for their difficulties,[7] or the power struggle involved in the role reversal of the female health worker/ male patient relationship.[17] Assey and Herbert[6] suggest that hospitalization so severely limits normal sexual behavior that patients may use seductive behaviors with health professionals because of feelings of isolation, needs for reassurance that they are sexually attractive, or needs to receive warmth and friendliness. Others have suggested that such behaviors may be related to the close physical proximity that is a necessary part of health care,[18] to the sexualization of caring,[19] or to stereotyping of people with disabilities as asexual.[20]

Sexual harassment has important effects on the victim. Feelings of frustration, embarrassment, fear, anger, culpability, confusion, annoyance, helplessness, depression, anxiety, isolation, alienation, being trapped, disbelief, shock, and hurt have been documented.[6,12,14,21,2]2 Physical manifestations of stress such as insomnia, headaches, digestive problems, chronic fatigue, various pains, and weight changes have been reported.[11-14] Victims must also deal with the attitudes of colleagues and friends who "may feel that in some way, perhaps unwittingly, victims of harassment bring this situation upon themselves."[12(p23)] Some individuals devise coping mechanisms, such as dressing plainly, in order to appear less attractive.[14]

In the nursing literature, several authors [6,7,21,23] have suggested that health care workers are often not prepared for the possibility of harassment by patients and react in a manner that increases the likehood of such behavior recurring. Savage18 suggested that education would help students begin to come to terms with their own sexuality and prepare them to cope with the sexual dynamics of their relationships with patients. Others[6] suggest that staff development in the area of sexual harassment would lead to improved patient care and a decreased likehood of future incidents.

It is clear that sexual harassment from patients occurs; however, the literature is narrow in its scope as it has focused almost entirely on the nursing profession. Because so much of physical therapy practice involves touching the patient and close interpersonal relationships, physical therapists may also be at risk. It is evident that the issue of IPSB in the physical therapy profession is inadequately addressed in the literature. For this reason, a survey of the experiences of physical therapy practitioners and students was conducted to describe the breadth of this problem in the Ottawa (Ontario, Canada) region. We hypothesized that (1) IPSB occurs in the physical therapy workplace and with varying degrees of severity; (2) IPSB is most prevalent among younger and less experienced physical therapists; (3) IPSB, like contra-power harassment, is not perceived as sexual harassment; and (4) the consequences of IPSB concur with those reported in previous studies. This study further explored the specific strategies that respondents used to manage IPSB and the perceived satisfaction and effectiveness of the strategies used. Finally, the survey sought to identify whether respondents perceive a need for in-service and undergraduate education.

Method

Subjects and Procedure

One hundred eighteen questionnaires were distributed to all physical therapists working in 4 major clinical settings (1 home care setting, 2 acute care settings, and 1 rehabilitation setting). The sample was a sample of convenience of physical therapists working at institutions that have clinical placements for physical therapy students from the University of Ottawa. This sample contained approximately half of all the physical therapists working with adults in hospitals, rehabilitation centers, and home care in the city of Ottawa. The questionnaire was also distributed to all 87 second-, third-, and fourth-year students (31, 25, and 31 students, respectively) enrolled in the physical therapy program at the University of Ottawa in 1992. All students had some full-time experience in the clinical setting, ranging from 2 weeks for the second-year students to 26 weeks for the fourth-year students.

The questionnaires were personally distributed by the researchers to the various workplaces and student classes. All respondents were asked to complete the questionnaire in their own time and to return it to the principal investigator (JM) in an accompanying self-addressed envelope. There were no follow-up reminders for unreturned questionnaires for either students or physical therapists. Restudents remained anonymous, as no names or other means of identification were on the questionnaire.

Instrument

The Inappropriate Patient Sexual Behavior Questionnaire (IPSBQ) was developed using two sexual harassment questionnaires used in university settings[24,25] and Grieco's nursing Sexual Harassment Questionnaire[8] as models for some questions. Each question was adapted to reflect possible experiences of physical therapists with IPSB and included demographic questions on age (grouped), sex, and years of experience of physical therapists or year of undergraduate study of students.

In contrast to the other questionnaires, the IPSBQ does not provide a definition of sexual harassment or IPSB; instead, questions are asked about several specific experiences, for example, "Has a patient ever 'propositioned' you (eg, asked you to have sex with him or her)?" Respondents chose from among the following answers: never, once, more than once (one individual), or more than once (different individuals). in the IPSBQ, specific behaviors are not labeled as sexual harassment" for two reasons. First, as noted previously, contra-power harassment may not be perceived as sexual harassment. Second, the term "sexual harassment" could be alernating.[17] The term "inappropriate patient sexual behavior" is used instead.

The IPSBQ contains a total of 45 questions: 13 pertain to specific behaviors experienced, 2 ask about sexual harassment, 15 relate to rotations and work settings, 5 ask about the effects of IPSB on the respondent, 5 inquire about responses to particular IPSB, 2 relate to the respondent's satisfaction with the way he or she had handled IPSB, and 3 ask for comments on how the respondent has dealt with this behavior and the necessity of undergraduate and inservice education. An open-ended request for comments is made at the conclusion of the questionnaire.

To establish content validity, the questionnaire was plot tested by a panel consisting of two physical therapy academicians, two physical therapy clinicians, and an epidemiologist. They were told the purpose of the study and the hypotheses and asked to complete the questionnaire. They were also asked to give feedback on the substance and structure of the questionnaire. The panel made few editorial corrections. The epidemiologist made suggestions for facilitating the analysis of the questions, and the wording of two questions was changed to eliminate ambiguity.

Data Analysis

To assist in the interpretation of the data, rather than analyzing the data separately by each behavior, the 13 questions pertaining to specific experiences of IPSB were divided into three categories. The "mild" category was composed of questions related to suggestive stories or offensive jokes, sexual remarks about the therapist's appearance, uncomfortable staring or leering, and asking for a date. "Moderate" IPSB included crude sexual remarks, discussions about the therapist's private sexual matters, propositions for sexual intercourse, and mild inappropriate touching. The "severe" category consisted of questions pertaining to deliberate sexual exposure, fondling, forceful touching, attempted rape, and rape. These categories are based on the sexual harassment literature. Grieco,[8] for example, reported that there was little disagreement among nurses as to the rating of the severity of the behaviors, and Fitzgerald and colleagues[25] found support for levels of sexual harassment ranging from gender harassment to sexual imposition.

Data were analyzed dichotomizing mild, moderate, severe, and any level of IPSB as never experienced versus experienced at least once. Amount of professional experience was defined as year of study for students and years of practice for physical therapists, divided into 1 through 5, 6 through 10, and more than 10 years of experience.

Data were examined using the SPSS/PC Version 4.01 software program.[*] Analyses included simple descriptive statistics, chi-square tests, and Fisher's Exact Probability Tests. Adjusted standardized residuals were calculated to locate sources of significance within specific cross-tabulations. The investigators acknowledge that repeated tests were conducted on correlated data (the same individual could report mild, moderate, and severe IPSB); hence, probability values should be considered in this context. Cramer's phi coefficients were calculated, where relevant, as an indication of the strength of association.

Results

Of the 205 questionnaires distributed, 152 were returned (68 from students and 84 from practicing therapists). The overall return rate was 74.1% (78.2% for students and 71.2% for practicing therapists).

More than 90% of the students were between the ages of 21 and 30 years, whereas about a third of the physical therapists were in each of the age ranges of 21 through 30, 31 through 40, and greater than 40 years. Most 89.0%) of the respondents were female. Of the 16 (11.0%) male respondents, 11 were students and 5 were physical therapists.

Breadth and Severity of

Inappropriate Patient

Sexual Behavior

Table 1 provides details on the percentages of students and physical therapists reported having experienced a specific IPSB at least once. The percentages of students and of practicing therapists experiencing mild, moderate, and severe IPSB are shown in Table 2. Separate chi-square tests were conducted to determine whether the percentage of respondents reporting mild, moderate, severe, or any level of IPSB (yes/no) varied as a function of student year or as a function of number of years of experience as a physical therapist. Among students, the association between proportion who reported having experienced IPSB and years of experience was statistically significant for each level of IPSB ([X.sup.2] values=9.62-13.78, df=2, P<.01; Cramer's phi coefficients=.38-.45). Fewer second-year students than expected experienced each level of IPSB adjusted standardized residuals were all greater than Z=3.0), and third-year students experienced significantly more moderate and severe IPSB than expected Z>2.0). Among physical therapists, none of the associations between experience of IPSB and years of experience were statistically significant (Cramer's phi coefficients =. 17-.21).

[TABULAR DATA OMITTED]

[TABULAR DATA OMITTED]

Students and physical therapists reported different experiences with IPSB. Compared with physical therapists, students reported less IPSB overall and at each level ([X.sup.2] values=8.89-17.33, P<.01-, phi coefficients=.24-.31).

Gender differences were observed despite the small number of male respondents (n=16). Overall, a higher proportion of women reported experiencing IPSB: 83.1% versus 56.3% of the men (Fisher's Exact Probability Test, two-tailed, P<.02). This gender difference was due to women experiencing more mild IPSB, but not moderate and severe IPSB, compared with men. Proportions of women versus men experiencing each level of IPSB were, respectively, 80.8% versus 56.3% for mild IPSB (Fisher's Exact Probability Test, two-tailed, P = .05), 61.6% versus 56.3% for moderate IPSB, and 32.8% versus 37.5% for severe IPSB. Although the proportions of female and male respondents experiencing severe IPSB were similar, a question-by-question analysis revealed that the male respondents had experienced similar rates of deliberate exposure but had not experienced inappropriate touching or force.

Respondents were asked whether they had worked with each of six classifications of rotations: amputations, bums, cardiorespiratory, neurology, orthopedics, and psychiatry. Whenever the response was "yes," they were also asked whether they had ever experienced IPSB on that rotation. The proportion of respondents reporting IPSB (never versus any level) varied as a function of rotation. About half of the respondents who had worked in orthopedics or neurology reported experiencing IPSB (52.8% of 142 respondents in orthopedics and 47.0% of 115 respondents in neurology). Reporting of IPSB was lower in other rotations: cardiorespiratory, 28.8% (n=104)-l psychiatry, 17.9% (n=28); amputations, 13.3% (n=60); and bums, 4.5% (n=44).

The questions about work settings were treated similarly. About half of those who had worked in an acute care, rehabilitation, or home care setting reported experiencing IPSB (53.3% of 122 respondents in acute care, 50.0% of 72 respondents in rehabilitation, and 51.1% of 47 respondents in home care). Experiences of IPSB were reported by about a third of those who had worked in long-term care or a private clinic (34.1% of 57 and 44 respondents, respectively). The lowest percentage of respondents reporting IPSB was among those who had worked in a nursing home (11.1% of 36 respondents).

Consequences of and

Responses to Inappropriate

Patient Sexual Behavior

Respondents were specifically asked whether they had ever "experienced inappropriate sexual behavior from a patient," and if so, to indicate the consequences. Among those who reported experiencing IPSB, significantly more students (57.1% of 35) than physical therapists (34.8% of 69) reported negative effects on work performance [x.sup.2]= 4.76, df= 1, P =.03). About one third of each group reported psychological effects (35.3% of 68 physical therapists and 34.3% of 35 students). Few individuals reported physical effects, financial repercussions, or having sought help for stress.

Students and physical therapists were asked to indicate how they had responded to five specific inappropriate patient behaviors; more than one response could be selected for each IPSB. Table 3 shows that the strategy of "ignore" was used most often by both groups of respondents to handle less serious incidents. "Ignore" was also used most often by students, for more serious behaviors, whereas physical therapists chose "discuss with patient" for these incidents.

Although 77% of respondents experiencing IPSB were satisfied with their responses to the behavior and 79% felt that they were effective in eliminating the behavior, most (>88%) believed that in-service and undergraduate education on this topic is important.

Perception of Sexual

Harassment

All 13 of the IPSBQ questions on specific client behaviors fall within EEOC's definition of sexual harassment.[10] Although 80.5% of all respondents (n = 120) indicated they had encountered at least one of these behaviors, only 24.2% of those who reported experiencing any level of IPSB responded positively to the question, "Have you ever been sexually harassed by a patient?"

Perception of sexual harassment appeared to be unrelated to the severity of the IPSB. Even among the 33.6% n=50) of respondents who had experienced severe IPSB, only 38% reported they had been sexually harassed. There was, however, a significant difference between students' and physical therapists' perception of sexual harassment. Only 13.3% (of 15) students experiencing severe IPSB reported being sexually harassed, compared with 48.6% (of 35) physical therapists (X.sup.2]= 5.53, df= 1, P <.05). This difference between students and physical therapists was significant overall (8.9% of 45 students experiencing any level of IPSB reported being sexually harassed, compared with 33.3% of 75 physical therapists ([X.sup.2] = 14.7, df = 1, P<.001).

Discussion

The results of our study concur with those of Crull and Cohen,(11) who reported that harassment by nonsuperiors (co-workers, customers, clients, patients, or students) occurs in the workplace. The high percentage of both students and physical therapists reporting IPSB and the fact that they are reporting many serious incidents support Grieco's statement: "The prevalence of sexual harassment is fairly high, and moderate to severe harassment, especially from patients, is not rare."(8)(p265) Contrapower sexual harassment does occur in the physical therapy workplace.

The questions about specific IPSBs (Tab. 1) all describe behaviors that are part of the definition of sexual harassment. It is clear, however, that the respondents to this survey do not perceive IPSB as sexual harassment. The fact that so few respondents reported having been sexually harassed, although troubling, is perhaps not surprising. Several authors(11,14,26) have suggested that people who have experienced contrapower harassment do not view it as sexual harassment. For example, in a survey of sexual harassment of women professors by students, Grauerholz(27) found that only 26.7% of the respondents who had been sexually harassed (by definition) agreed that it was sexual harassment.

Pryor(28) has suggested an attributional model to explain people's understanding of sexual harassment. Attribution theorists believe that people interpret behaviors in terms of perceived causes. Thus, the respondents in our study may not have attributed the behaviors to sexual harassment because the patient behavior may not have been perceived as hostile or callous toward them.(28) They may have blamed themselves for the incident, or traditional sex-role beliefs (ie, beliefs that it is normal for a woman to be passive and for a man to be aggressive and opportunistic) may have influenced their perception of sexual harassment.(29)

Unwillingness to label IPSB as sexual harassment may be one of the reasons why the situation is so largely ignored in health care establishments. If IPSB is considered just "part of the job," it may be tolerated by the professional. Regardless of whether IPSB is labeled as sexual harassment, such behaviors lead to a number of adverse consequences and hence are a problem for the physical therapist.

The results of our study suggest that fewer second-year students have experienced IPSB than other respondents. We view this as evidence that the questionnaire is sensitive to limited clinical experience, as these students had only completed one 2-week clinical placement. Surprisingly though, these second-year students had experienced IPSB despite their limited experience, albeit the behaviors were of a less severe nature (ie, none had experienced severe IPSB).

That "sexual harassment affects proportionately more women than men"(12)(p21) is a common perception, despite the fact that few surveys have been conducted that have included men. Although the number of men in our study was quite small, the fact that a significantly lower percentage of men reported any IPSB, and in particular mild IPSB, may mean that more women than men are the object of sexual innuendos. The results that both men and women in our sample reported experiencing moderate to severe IPSB, however, indicate that male physical therapists should be included in education programs dealing with IPSB.

The IPSB questionnaire developed for this study represents the first attempt to identify on which rotations and in which settings IPSB is actually occurring. A brief review of the comments at the end of the questionnaire indicates that some respondents believed neurology to be a key rotation for the occurrence of IPSB. Others have suggested that remedial efforts should be focused on dealing with the patient with neurological problems. This perception may stem from the fact that patients experiencing a neurological deficit may present a tangible cause for IPSB, such as medications that affect behavior, specific behavior disorders, or a patient's struggle with his or her sexuality. The data from this study do not support this view, as the highest proportion of respondents had experienced IPSB on an orthopedics rotation. Similarity of prevalence of IPSB across acute care, rehabilitation, and home care settings suggests that undergraduate or in-service education should not be focused on a given area.

Students in this sample have experienced negative effects on their work performance, such as distraction or decreased productivity, to a greater degree than physical therapists. Over half of the students who reported experiencing IPSB may not have been confident in their ability to deal with IPSB during their clinical placements. Although both physical therapists and students experienced psychological effects, such as guilt or depression, to an equal extent, students tended to seek less help for the stressful effects of IPSB. Students chose to ignore even the more serious incidents and did not discuss the incidents with the patient. This finding suggests that these students were more likely than physical therapists to feel alone in dealing with the stress. Not only was their learning experience affected, but the quality of patient care may also have been decreased during their clinical placements. The findings of this survey support the views held by Assey and Herbert,(6) who stress the importance of dealing with advances adequately in order to improve patient care and to decrease stressful effects on recipients.

Two reasons have been suggested to explain why students and professionals tend to ignore IPSB. Respondents may be using silence to effectively eliminate IPSB or may be using it as a blanket strategy, which may contribute to its recurrence.(6) Brooks and Perot(26) support the view that silence helps to maintain the existence of sexual harassment and suggest that the silence may stem from a widespread misconception about what actually constitutes sexual harassment. They state, "These misconceptions may well encourage a continuation of harassment insofar as they discourage victims from objecting."(26)(p46)

Grauerholz(27) has reported that the most effective strategy is to directly confront the harasser. An encouraging finding in this survey is that many physical therapists reported discussing the behavior with the patient. It is essential that students recognize and deal with IPSB in this way as well. Two textbooks(30,31) have been written by physical therapists to teach skills related to patient-practitioner inter-action. Although these textbooks cover the skills of communication that can be very useful when dealing with sexual harassment situations, neither text specifically covers sexual harassment. It is important that we not only learn the skills to work with our patients as people but also that we learn to recognize what is happening in the communication system and have strategies available when difficulties with interactions arise. This aspect of health professional and patient interaction should be covered directly in our education programs.

Limitations

This study of IPSB was done in one urban region in Canada. Studies have not specifically examined regional variations in sexual harassment. Currently, therefore, there is no evidence of regional differences in sexual harassment nor is there evidence that there are differences in the prevalence or perception of sexual harassment between Canada and the United States.(1,4) Similar experiences with sexual harassment have been documented in the two countries, and the recent responses by the respective governments and action groups have been similar.(32,33) A larger, more diverse sample, however, would facilitate generalizability of this study. The IPSBQ has content validity, but test-retest reliability must be established if the questionnaire is to have more extensive use. This study did not find a hypothesized inverse effect between years of experience and risk of experiencing IPSB. One reason may be that because therapists were asked to document experiences with IPSB over the span of their careers, this would increase the prevalence in the more experienced therapists. Future data from the questionnaire would be more precise if the questions were framed within a time context. For example, questions in the questionnaire could be worded: "In the past year, have you ever been in a situation ... ?" This modification would help to interpret the data related to age and years of experience.

Conclusion

In this sample, IPSB did indeed occur to a significant extent, at all levels of severity, to physical therapists of all levels of experience and to both women and men in the physical therapy workplace. Respondents did not perceive that IPSB is sexual harassment. This finding emphasizes the need for education that will lead to an increased awareness of the issue of IPSB in all its dimensions. Respondents reported that there were effects of IPSB on the physical therapist and in the workplace that need to be addressed by the profession, by educators, by employers, and by the individual. We conclude that this problem should be addressed by further study with a broader sample and by inclusion of these issues in education programs for students and physical therapists.

Acknowledgments

We thank Katherine Harman, Monica Prince, Diane Roller, and Meryn Stuart for their assistance and helpful suggestions.

References

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