“That Is So Common Everyday . . . Everywhere You Go”: Sexual Harassment of Workers in Assisted Living

Abstract

In assisted living (AL) facilities, workers are intimately involved in the lives of residents. Existing research on AL demonstrates the imbalance of this environment, which is a personal home for the residents and a workplace for staff. Using observational and interview data collected from six AL facilities, this grounded theory project analyzes how AL staff define, understand, and negotiate sexual comments, joking, and physical touch. We developed a conceptual model to describe how such harassment was perceived, experienced by AL workers, and how they responded. Sexualized behavior or harassment was experienced by workers of every status. We found that words and actions were contextualized based on resident and worker characteristics and the behavior. Staff members refused to engage residents, redirected them, or reframed the words and gestures to get the job done. Reporting the incidents was less common. We conclude by discussing implications for policy and research.

Prior to the 1970s, navigating a sexually charged workplace was an expected but little discussed part of the workday for many workers. In the 1970s and 1980s, scholars such as MacKinnon (1979) reframed the discussion about sexual behavior in the workplace. In the ensuing decades, academic research, legal scholarship, and social policy problematized sexual power dynamics in the workplace. Today, sexual harassment is considered a form of workplace discrimination by the U.S. Equal Employment Opportunity Commission (US EEOC, 2015), which defines it as “unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature” that interferes with one’s employment or work performance or creates a “hostile or offensive work environment.” In spite of increased attention and legislation, sexual harassment remains a serious problem. The majority of women and a significant minority of men report experiencing sexual harassment in the workplace at least once (Uggen & Blackstone, 2004; Welsh, 1999).Yet the experience of sexual harassment remains subjective based on individual experience and organizational context (Welsh, 1999). Furthermore, many workers who experience sexual harassment do not have legal or institutional resources to stop it (Huebner, 2008).

Workers who experience sexualized behavior in the workplace do not always label it as sexual harassment. Sexual interactions in the workplace can range from flirting and teasing to physical encounters and have varied and contradictory significance (Williams, Giuffre, & Dellinger, 1999). Individual and structural factors shape how and whether workers define this as harassment (Welsh, 1999; Williams et al., 1999). Workers are more likely to define non-consensual, persistent, or abusive sexual behaviors as harassment (Giuffre & Williams, 1994; Welsh, Carr, MacQuarrie, & Huntley, 2006). Moreover, race, class, age, gender, job status, and organizational culture contextualize sexual harassment (Blackstone, Houle, & Uggen, 2014; Welsh et al., 2006; Williams et al., 1999).

In this article, we examine an often invisible form of harassment: the sexual harassment of workers in assisted living (AL) facilities by residents. AL provides a unique environment for studying sexual harassment because the AL industry advertises a home-like environment that emphasizes residents’ choice and control. But it is also a workplace for staff, the vast majority of whom are female, who can develop long-term nurturing relationships with residents. Using data from a qualitative study of six AL facilities in metropolitan Atlanta, we examine how AL workers and administrators manage sexual harassment or inappropriate behavior.

Sexualized Behavior and Harassment in Health Care

Although many health care workers encounter sexual behavior in the workplace (Deery, Walsh, & Guest, 2011; deMayo, 1997), existing research has focused primarily on nurses. Spector, Zhou, and Che (2014) found that 25% of nurses were exposed to sexual harassment. Patients are the most common perpetrators of sexual harassment, and both male and female nurses are victims (Bronner, Peretz, & Ehrenfeld, 2003). However, patient behavior is not regulated by employment guidelines and depends largely on the culture of the institution. Furthermore, sexual behavior is not always perceived as problematic. Although nurses report inappropriate sexual behavior from patients, they are hesitant to define it as sexual harassment (Huebner, 2008). Because incidents are often isolated and patients are vulnerable, nurses do not perceive this as a problem but part of the job for which they are prepared and trained. In addition, the context of the sexual behavior, such as the severity of the incident and the identity of the perpetrator, influences whether it is perceived as sexual harassment by health care workers (Daly, Banerjee, Armstrong, Armstrong, & Szebehely, 2011; deMayo, 1997).

Sexual harassment becomes invisible in nursing for numerous reasons. In hospital settings, nurses balance the emotional and physical needs of patients through a set of intimate exchanges (Ruchti, 2012). According to Ruchti (2012), these nurses asserted that successfully negotiating these interactions was a result of their professional approach to medical and health care work. Despite a lack of training on managing sexual harassment from patients, nurses prided themselves in handling challenging situations (Ruchti, 2012). When patients are perceived as vulnerable, confused, or in pain, their actions are minimized or excused (Huebner, 2008; Ruchti, 2012). It is only when nurses perceive the behavior as intentional and likely to reoccur, that it is defined as sexual harassment (Deery et al., 2011; Huebner, 2008; Ruchti, 2012). The burden for managing these sexually charged interactions falls on individual nurses (Madison & Minichiello, 2004). As a result, the collective exposure to sexual harassment is minimized.

While patients, mostly male, act in sexually charged or inappropriate ways, nurses frequently dismiss the behavior labeling patients as confused or harmless (Blackstone et al., 2014). Moreover, nurses and supervisors naturalize behavior claiming that “men are just like that” and believe nurses should be responsible for policing inappropriate behavior. Without training on managing intimate conflict, nurses were responsible for negotiating these interactions on their own. Thus, the burden and stress of sexual harassment is perceived as a personal problem, not a structural one. Over time, nurses develop strategies for managing sexual harassment (Blackstone et al., 2014). Ethnic minority nurses (or health care workers) may be more likely to define these issues as problematic (Barling, Rogers, & Kelloway, 2001; Deery et al., 2011).

Cultural stereotypes of nurses as sexy, flirtatious, or promiscuous reinforce the belief that nurses are sexually available (Madison & Minichiello, 2004; Ruchti, 2012). In unsupportive workplaces, these stereotypes reinforce a culture of silence around sexual harassment (Madison & Minichiello, 2004). These stereotypes and sexualized behavior of patients negatively influence the ability to get work done. These disruptions may be momentary or require more significant emotional and temporal attention. Ultimately, sexual harassment may contribute to burnout or poor job retention (Deery et al., 2011).

Gaps in Research on Sexual Harassment in Health Care

Although there is a growing body of research on sexual harassment in health care, it has focused on nurses in hospital settings. There is little research about sexual harassment in long-term care (LTC) or geriatric settings. Within health care, workers have differential access to resources depending on where they work and what they do. Fear of workplace violence and sexual harassment can influence job performance and mood (Barling et al., 2001). Direct care workers (DCWs) in LTC have on-going relationships of caregiving, which may be one of the most salient aspects of the job (Ball, Lepore, Perkins, Hollingsworth, & Sweatman, 2009). Strong interpersonal ties to residents may offset some of these negative aspects of these low status, difficult jobs with high turnover and low pay (Berdes & Eckert, 2007; Stone, 2004). Conversely, negative interactions and poor relationship quality may impact job satisfaction, turnover, and sick days (Clausen, Hogh, & Borg, 2012; Stone, 2004). At worst, DCWs deal with both verbal and physical abuse on the job (Ball et al., 2009; Berdes & Eckert, 2007). Lower status workers such as DCWs may be more vulnerable to issues of sexual harassment.

Building on existing research, this article examines how AL staff and administrators define, understand, and negotiate sexual and intimate comments, joking, and physical touch.

Method

This analysis is part of a larger National Institute on Aging (NIA)-funded qualitative study investigating how residents negotiate sexuality in AL facilities. The data collection was cross-sectional and spanned 2 years from 2009 to 2011. The data were collected from six AL facilities in the metropolitan Atlanta area. The data we use in this analysis focus on administrators and staff. The institutional review board at Georgia State University approved all of the procedures (#H08476). The names of the facilities and individuals are all pseudonyms.

Setting and Participants

We purposively sampled six AL facilities in the metro Atlanta area for maximum variation, selecting homes that varied in location type (urban, suburban, and exurban), size, price range, ownership type, and resident demographics. Three of our homes were medium sized and had less than 50 residents: Rosewood Hills (43), Somerset Manor (48), and White Sands Plantation (40). The remaining homes had more than 50 residents: Forest Glen (90), Aster Gardens (65), and Sycamore Estates (58). Four were corporately owned, one was family owned, and one was a non-profit. The homes ranged in size from 50 to 109 beds. Fees ranged from $1200 to $5545 per month depending on the level of care provided.

Although there was variation in terms of location, size, and cost, the homes were similar in terms of resident demographics (age, sex ratio, level of support needed). And although we aimed for maximum variation in sampling, AL residents are more likely to be female, middle class, and White (Caffrey et al., 2012) and our sample reflects that. All residents required some assistance with activities of daily living.

The majority of residents and administrators were White, and the majority of staff in this study were minorities and women. This is consistent with national trends (Institute of Medicine [IOM], 2008). We primarily interviewed DCWs, but because many other staff interact with residents, we also included activity directors, kitchen and dining staff, clerical workers, a maintenance employee, and direct care managers. See Table 1 for a comparison of respondents.

Table 1.

Socio-Demographic Characteristics of Staff and Administrators.

	Staff (N = 49)	Admin (N = 6)
	n (%)	n (%)
Age
0–34	18 (36.7)	0 (0)
35–44	14 (28.4)	2 (33.3)
45–54	11 (22.4)	1 (16.7)
55 and above	6 (12.2)	3 (50)
Gender
Female	44 (89.8)	4 (66.7)
Male	5 (10.2)	2 (33.3)
Race
Black/African American (non-Hispanic)	33 (67.3)	0 (0)
White/Caucasian (non-Hispanic)	10 (20.4)	5 (83.3)a
Other	6 (12.2)	0 (0)
Education
<HS	4 (8.2)	0 (0)
HS diploma	43 (87.8)	2 (33.3)
Bachelor’s degree	1 (2.0)	3 (50.0)
Some post-graduate	1 (2.0)	1 (16.7)
Position
Activities	5 (10.2)
Care worker	31 (63.3)
Clerical	2 (4.1)
Dining	4 (8.2)
Housekeeping	2 (4.1)
Maintenance	1 (2.0)
Supervisor	4 (8.2)
Tenure in position
<1 year	19 (38.8)	0 (0)
1–5 years	24 (49)	3 (50.0)
>5 years	6 (12.2)	3 (50.0)
Experience in LTC
<1 year	11 (22.5)	0 (0)
1–5 years	12 (24.5)	1 (16.7)
>5 years	25 (51)	5 (83.3)

Note. HS = high school; LTC = long-term care.

^aOne administrator declined to report race.

Data Collection

Data collection involved observations, interviews with administrators, staff, family members, residents, and focus groups with staff in each home. The primary investigator (PI) and a team of trained graduate students collected the data. The PI gained consent and conducted a semi-structured interview with each facility administrator. Following the administrator interview, the team was introduced in staff meetings, resident council meetings, and in community newsletters. Subsequently, the team spent time in each home, volunteering and attending activities to observe, build rapport, and recruit respondents for focus groups and interviews. The team conducted approximately 200 hr of observation documented in detailed field notes.

In each facility, we conducted open-ended semi-structured individual interviews with administrators (6), staff (22), residents (24), and family members (9). The interviews took place in a private space within the AL facility, including residents’ rooms, private dining rooms, conference rooms, or administrative offices. Prior to conducting the interviews, respondents completed the informed consent process and answered a short demographic survey. The interview questions varied by category of respondent.¹ Questions for administrators included (a) employment history and daily work routine, (b) training and policies regarding sexuality and intimacy, and (c) experiences with resident sexuality and intimacy at their AL facility. Questions for staff interviews included (a) work experience and routine at their AL, (b) experiences with the sexual and intimate behavior of residents, (c) definitions and examples of appropriate and inappropriate sexual and intimate behavior, (d) how does residents’ sexual or intimate behavior affect their job, (e) knowledge and attitudes regarding the relationship between sexuality and intimacy and dementia, and (f) policies and trainings regarding intimacy and sexuality. Questions for residents included (a) their decision to move to AL, (b) their daily experience of living in AL, (c) opportunities for privacy, (d) experiences of sexual and intimate behavior in AL (in regard to themselves or other residents), (e) definitions and examples of appropriate and inappropriate sexual and intimate behavior, and (f) attitudes, opinions, and concerns about sexual and intimate behavior. Family members were asked about (a) the decision to move to a family member to AL, (b) their involvement with the facility, (c) observations and experiences regarding sexuality and intimacy in the facility, (d) definitions and examples of appropriate and inappropriate sexual and intimate behavior, and (e) attitudes, opinions, and concerns about sexual and intimate behavior among residents in AL. The interview schedules ranged from 12 to 20 questions. Each question was followed up with three to five probing prompts to elicit more detailed information. The themes of the interviews remained constant throughout the data collection, but the follow-up probes were revised after data collection in the first two AL facilities to elicit more information on emergent themes (Strauss, 1987; Strauss & Corbin, 1998). In addition, we conducted six focus groups with staff (27 focus group participants). To accommodate staff schedules and facility staffing needs, we conducted two focus groups at Forest Glen (a larger facility) and conducted additional individual interviews but no focus group at White Sands Plantation (a smaller facility). At each of the other facilities, we conducted one focus group with staff. Focus groups are useful for illuminating norms and assumptions that are hard to capture during individual interviews and eliciting information on controversial or sensitive topics (Madriz, 2000; Morgan, 2003). During the focus groups, we paid particular attention to how staff members interpreted sexual and intimate behavior of residents, how they made meaning of residents’ rights and sexual freedoms, and how they agreed, disagreed, and came to consensus on these meanings. This analysis focuses on administrators and staff. On average, the administrator interviews lasted 50 min, the staff interviews lasted 40 min, and the focus groups lasted 60 min.

Data Analysis

All interviews and focus groups were digitally recorded and transcribed in their entirety. The research team used NVivo 10 to assist with data management and storage of all qualitative data and SPSS 16 for descriptive statistical information. Over the course of the project, the PI, six trained graduate students, and two co-investigators participated in open coding of the data and data entry. We analyzed the data using principles of grounded theory methods, which are useful for developing theory inductively (Glaser & Strauss, 1999; LaRossa, 2005; Strauss & Corbin, 1998). We began with open coding, a line-by-line reading of the text, looking for emergent themes. At least two coders reviewed each transcript, and during regular meetings the team came to consensus on discrepancies, new codes, and overall impressions. The coauthors of this article, a subset of the larger team, conducted the analysis for harassment. We categorized similar contexts into codes, continually comparing the codes with each other to look for similarities and differences (Glaser & Strauss, 1999; LaRossa, 2005). For example, codes such as harassment, cognitive status, and problem behavior emerged via a detailed reading of the text. As harassment emerged as a salient theme among administrators and staff, we revised our interview guides to probe further on worker’s experiences regarding unwanted sexual attention. Axial coding involved examining how initial categories were linked to other categories, paying particular attention to co-occurrences of categories, context, contingencies, and strategies (Glaser & Strauss, 1999; LaRossa, 2005). For example, we examined how staff perceptions of harassment were influenced by the resident’s gender and cognitive status. We also compared participants across homes and roles, creating diagrams and memos to assist in analysis. Finally, we developed a model (see Figure 1) to represent how staff perceived and managed sexual overtures from residents. Using grounded theory methods, we found that harassment emerged as a salient theme for administrators and staff but was largely invisible to family members and residents. Therefore, this analysis concentrates on the experiences of administrator and staff.

Figure 1.

Conceptual model of understanding and negotiating sexual harassment in AL.

Note. AL = assisted living.

Results

Pervasiveness of Sexual Harassment in AL

In each of our homes, AL workers experienced sexually inappropriate behavior both in private and public areas of the facilities. Regardless of whether they identified it as sexual harassment, both male and female workers, from dishwashers to administrators, dealt with sexualized conduct from residents. In her interview, Carol, a DCW at Somerset Gardens, illustrates how common and pervasive this behavior can be. It often begins innocently but quickly crosses a line to inappropriate:

Interviewer: Has a resident ever acted in a sexual or romantic way toward a coworker or a staff member that you’ve seen?

Carol: All the time . . . Yes, and it’s men and women . . .we’ll go into the dining rooms, it’s just a common little nice gesture of a hug, and it ends up being, looking down your shirt and commenting on it, asking to see more, offered to put money to see more, grabbing your rear end, popping you on the rear end. That is so common everyday [laughs] everywhere. Everywhere you go.

For Carol, managing sexually inappropriate conduct from residents was part of her work environment every day. We found that perceptions and responses to sexual harassment depended on the characteristics of the resident and the worker. In the sections that follow, we develop a conceptual model that examines the various ways that workers negotiate these and other sexualized behaviors in AL. This model illustrates how staff and administrators perceive, experience, and respond to the sexual harassment of workers by residents (see Figure 1).

Perceived threat of sexual harassment.

Residents’ sexual conduct was not always perceived as threatening or defined as sexual harassment. As illustrated in the conceptual model, both worker and resident characteristics influenced how individuals interpreted and responded to the situation.

Worker characteristics.

In this sample, worker characteristics influenced how they perceived sexual behavior. Most of the workers were female. Male workers were less likely to see inappropriate behavior as a threat and more likely to identify it as joking or flirting. We found that younger and less experienced workers struggled with managing resident behavior. With age and tenure on the job, workers began to experience this as “part of the job.” The status of the worker also influenced their perception of the behavior. DCWs had the most intimate contact with the residents and thus were more likely to experience physical touch and persistent harassment. Dining or maintenance staff had less direct contact and were more likely to dismiss it. As managers, administrators had the least intimate contact with residents, and these issues were less visible or perceived as non-threatening. Gender, age, tenure on the job, and type of job interact to shape how workers perceive sexually inappropriate behavior.

The following quote from the Aster Gardens focus group illustrates how Laura was initially shocked and perceived this behavior as problematic. But over time, she learned to frame sexualized behavior as part of her job. Laura explains,

When I first started . . . I said, “Oh my God! No you did not!” And I said, “I’m telling.” And [the resident] was like, “You don’t have to [tell], honey. Just sit here.” And I’m like, “No, I’m not sitting there.” [Laughs]. . . [but] you can’t just keep going to your manager each time.

Like other DCWs, with experience Laura learned how to negotiate sexually inappropriate behavior on her own.

Gender and worker status also influenced how workers experienced sexually charged situations. Lester, a male cook from Sycamore Estates, does not perceive the sexual overtures of residents as problematic. He says,

. . . sometimes I throw a little flirt back in there, just to play around of course, but it’s gets them happy, it gets their spirits up, you know, ‘cause I’ll go around and be like, gosh you guys look just so gorgeous today and then it’s just amazing how big their smile gets just to hear that.

Lester’s job in the kitchen involves less intimate contact than Laura. For him, teasing and flirting were a way to communicate with residents. Lester initiated sexually charged conversation and did not feel threatened by it.

Although Steve, the administrator at Somerset Manor, did not instigate sexual talk, he was not troubled by behavior that could have been perceived as sexual harassment by other workers.

Steve: I get tons of hugs and kisses, and you know they’ll tell me they love me and they’ll say, “Oh, you’re good looking.” . . . But I’ve had them grab my butt. Stuff like that, when I walk by, or whatever, you know, [they] pat me.

Interviewer: Does that ever get to a level where you have to say that it’s inappropriate?

Steve: No, . . . I just take it in good spirits.

As a result of his privileged status as an administrator and man, Steve did not judge these interactions as inappropriate.

Resident characteristics.

In this sample, resident characteristics also influenced how workers perceived sexual behavior. All residents were older than workers and many workers noted discomfort with viewing older adults as sexual. In the Rosewood Hills focus group, Dorothy said, “Would you believe it, somebody that’s like your great-grandfather’s age, you think he’s flirting with you?” Perceptions of older adults as asexual influenced whether staff, particularly those who were younger, were threatened by sexual language and behavior.

Age of residents was frequently addressed when discussing sexually inappropriate behavior. Lacey, a DCW from Aster Gardens, excused inappropriate behavior as unintentional because of the age of residents. Lacey explains,

. . . some of the residents, the men, will make, I don’t know if you want to consider it an advance . . . whatever you want to call it, I don’t like it. . . . I think it’s disgusting, but the reason I don’t make a big deal over it, because, I know it has a lot to do with their age, they don’t know whether or not it’s offensive, I don’t think, ‘cause if they did, I don’t think they would do it. But, it does disgust me, but it’s not the end of the world. I handle it, I just deal with it, I don’t like it, but I deal with it.

In other cases, workers excused behavior that they perceived as expected behavior for residents with dementia. Shirley, a supervisor from Somerset Manor, was more tolerant of harassing behavior from residents with dementia or impaired cognitive status.

Shirley: In [the] dementia [unit] you would see more of the sexuality coming out. And that’s proven . . . if you read the research on dementia. We see a lot of [cognitively impaired] residents get more in touch with their sexuality. . . .

Interviewer: And why do you think that is?

Shirley: . . . I don’t know. We just know that it’s a common thing. It’s proven.

Like Shirley, many DCWs were more tolerant of harassing behavior from residents with dementia. In some cases, workers claimed that their assessment was based on “research,” as Shirley explains in the quote above, but the majority of AL staff had received no formal training regarding sexuality and dementia. Instead, their assessments were based on experience, shared knowledge, and public opinions not scientific research. DCWs dismissed or excused inappropriate sexual behavior of cognitively impaired residents, because they perceived that the residents did not intend the behavior to be harassing.

Both male and female residents instigated harassing behavior, but male residents were more likely to be seen as threatening and problematic, whereas female residents’ behavior was perceived as harmless joking and flirting. Perceptions of cognitive status and functional ability of the residents also influenced how workers interpreted sexual behavior. Workers modified descriptions of sexually inappropriate behavior with descriptions of memory loss. Age, gender, and cognitive and health status of residents interacted to shape how workers perceive sexually inappropriate behavior and how they respond to it.

When asked whether staff reported sexually inappropriate behavior, Steve, the administrator quoted above, said, “not really . . . I haven’t heard from any of the girls. . . . I’ve never heard anything about a male resident being inappropriate with one of my female staff here.” Steve’s quote reinforces the belief that only male residents sexually harass staff members.

Understanding sexual behavior.

The appropriateness of residents’ sexual conduct was also determined by the frequency, severity, and context of the behavior, which in turn influenced perception (see Figure 1). As discussed above, workers had different thresholds for behavior depending on characteristics of the workers and residents. Tolerance was afforded to verbal advances more so than physical touch, and flirting and teasing were more likely to be perceived as acceptable. For some workers, such as Lester, quoted above, sexual banter was perceived as an appropriate and harmless way to interact with residents. But flirting can be perceived as a gateway to other behaviors.

Patty, a DCW at Aster Gardens, discussed her opinion about the appropriateness of residents’ behavior, “sometimes flirting verbally is ok, but sometimes they, at times, want to start touching, and that becomes really uncomfortable.” For workers like Patty, physical touch represents the most threatening behavior. Verbal advances were also problematic when residents gave an explicit verbal command that presented an eminent threat. In the Aster Gardens focus group, Laura gave an example of verbal advances crossing the line, “you sit next to them to give them their meds and some male will say, ‘I would love to get in between your legs.’ And I’d be like, ‘Oh no you wouldn’t.’”

As illustrated by Carol’s quote earlier, the frequency of sexualized behavior also influenced how it is perceived. More frequent behavior was considered inappropriate. How sexually harassing behavior is perceived influences how AL workers respond to sexual overtures.

If workers perceived the behavior as out of character for the resident, whether it was a new behavior or a change in the frequency or severity of sexual harassment, then they were quick to identify it as problematic and to inform the supervisor. Maggie, a DCW in the Aster Gardens focus group, shared,

Then he told me he wanted to unbutton my shirt . . . He said, “I want to see your breasts.” You know it was just really crazy. And then today he said, “I’m watching,” he said, “I’s watching your butt. I’m watching your behind” He said, “I want to pat it.” And you know, it was just like really really out of character for him. So of course I had to report it.

In the following quote, Abby, a DCW from White Sands Plantation, discusses sexually inappropriate behavior that increases in both frequency and severity:

The one man he had, you know, he was playing with himself. And he make certain gestures. And he even make gestures at the staff, too. When it became annoying, then we finally told management. And that’s when they realized something needed to be done. He would do it, like, if we’d go in his room. He’ll make gestures at us. And we understand, oh maybe he’s going into memory problem. But then when [the behavior] became more and more common every day, [management] realized that it was becoming a habit.

Response.

AL workers responded to residents’ sexual behaviors by controlling the situation themselves or by reporting the behavior. Decisions about how to react to inappropriate behavior were framed by perceptions of whether the behavior was threatening to themselves or other residents.

Controlling the situation.

In the majority of situations, AL workers believed it was their responsibility to control the situation. They did this by refusing to engage the resident in a sexual way, reframing the situation to eliminate sexual innuendo, or by redirecting the resident to other behavior. Experienced AL workers expressed pride in their ability to control the situation by keeping interactions professional. This was the delicate balance between being assertive and not reacting to sexually inappropriate behavior while still keeping the residents happy. Lilly, a housekeeper at White Sands Plantation, reported “I don’t have a problem with it because it’s my choice if I want to engage in it and I wouldn’t do nothing like that.” Marsha, a DCW from Somerset Estates, explains her response in the context of the severity of the behavior:

. . . he needed to keep his hands to his self. . . . I would say, “Now you know, if you want to pat me on the back or hold my hand or shake my hand, that’s fine. But you don’t need to be touching private body parts.” I would probably just handle it that way and go on about my business.

AL staff also controlled the situation by reframing the encounter. Younger and less experienced workers were more likely to reframe the situation by defining themselves as inappropriate targets of sexual overtures. The most common responses were to emphasize the age difference or to remind the residents that they had a boyfriend or husband. When asked how she responds to inappropriate behavior, Patty, quoted above, tells residents “[I] tell them that I’m married and my husband would be very unhappy about this, if my husband was here he would want to fight you, then they back up.”

In some cases, workers discounted the severity of sexually harassing behavior by defining it as “part of the job” which they had to “deal with.” Roxanne, from the Sycamore Estates focus group, describes how she deals with sexualized behavior as part of her job in this quote: “we have another guy, he will want you to wipe him because he wants you to touch his private and stuff like that, but I just do my job and get on with it, I don’t listen to them.”

If the behavior was rare or stopped when the workers requested, then it was more likely to be seen as part of the job and not threatening. Lilly, a housekeeper from White Sands Plantation, explains how the behavior of one male resident ended with her request:

one of the residents he said, “Come here, let me rub your breasts.” I’m like, “I don’t do that.” He said, “Well the girl at night let me do it.” . . . “Well, I don’t do it.” I said, “I’ll . . . I clown [around] with you but we don’t cross that line.” . . . And he never asked me again.

These responses minimized the significance of inappropriate behavior rendering it invisible.

The final way that workers controlled the situation was redirecting the behavior. Humor was a common way that workers de-escalated potentially volatile situations. In this quote the Sycamore Estates focus group, Roxanne describes how she used humor to maintain control:

I try and turn it into joking sometimes, I try to let them know like don’t do it, but I’m not upset with you, because a lot of times you know they’ll automatically think that you’re mad at them for it or that they did something wrong, so I try to just play it off and let them know that it’s wrong, but at the same time not make them feel terrible.

By responding to inappropriate behavior with a gentle smile or a teasing comment, workers maintained control of the situation without humiliating the resident. Frequent and more severe behavior required more active strategies for redirection. In Forest Glen focus group, staff members discussed the strategies they use to redirect the behavior. After discussing how to keep your distance while providing care, Mark illustrates the importance of co-workers to negotiate inappropriate behavior:

Or you go with somebody if you know that this [resident] wants to be too intimate. And you say, “Hey, can we go together into that room?” You need not divulge why you are inviting that person. But as you go in, then [the resident] won’t go into that business.

These strategies allowed workers to control the situation and avoid sexual encounters or prevent them from escalating. Workers shared these strategies with peers and warned co-workers if a resident was particularly inappropriate.

Reporting the behavior.

At times, the response to sexually inappropriate behavior was to report it to a supervisor. Workers reported sexually explicit behavior when they were concerned about their own welfare and that of the residents. Lilly, a housekeeper at White Sands Plantation explains why she felt it was important to report the behavior of a particular resident:

I spoke with the [administrator] and let them know . . . Because [this resident] was very strong. But if they are doing it in a joking manner, I still let her know because I don’t want nothing to be kept a secret. And if something was to happen [with the resident], [I don’t want her to say] “Well [why] you didn’t tell me this a while back.”. . . So I let her know everything that goes on.

Like Lilly, workers reported behavior out of concern for their jobs. They wanted to make sure their supervisors were aware of the situation and that they were following protocol. As the employees with little power and control in the workplace, DCWs, housekeeping, and dining staff wanted to avoid misunderstandings. Several workers spoke about concern that if there were any kind of dispute, resident or family member’s side of the story would be considered more reliable.

Administrative response to inappropriate behavior toward staff varied across the homes. Four of the administrators fluctuated between expecting workers to respond to inappropriate behavior by managing it themselves and expecting them to report it. Heather, the administrator at Aster Gardens, said she talked to staff “about uncomfortable behavior and being respectful of people as individuals.” Heather goes on to say that staff should “go back and look at where were they when the situation occurred. Because is there a way they could prevent [it]?” When elaborating on the importance of reporting, Hope, the administrator at Forest Glen also suggests this is discussed during orientation:

That is part of our orientation . . . if a resident is harassing a staff member it needs to be reported to their supervisor and then we investigate. And then vice versa if it’s, you know, two staff members. If they feel there’s some kind of harassment or sexual harassment going on, first thing they do is report it—first thing, of course, you always do is say stop. And then you know, you report it to your supervisor. And that is part of our orientation and training.

Betty, the administrator at Rosewood Hills, tells her care staff to respond by telling the resident that those words or behavior are not appropriate. If that does not eliminate the behavior then Betty “would go to the resident. And then the next step after that I would go to the family member.” In each case, administrators stressed the importance of reporting inappropriate behavior but also expected staff members to manage the behavior with little or no training.

The two male administrators did not perceive sexual harassment or inappropriate behavior to be an issue for their staff. As quoted earlier, Steve claimed not to have heard complaints about sexual harassment for any of “the girls.” Similarly, Wayne, the owner–administrator from Sycamore Estates estimated that he has only had to intervene twice in over 16 years. Male privilege and power may have rendered sexual harassment largely invisible to the male administrators that we interviewed.

Discussion

AL is marketed as a LTC option, which balances resident autonomy with a safe environment that provides some assistance for increasingly frail older adults. But it is also a workplace where care staff, housekeepers, dining staff, managers, administrators and others work. As existing research on AL has discussed, it is difficult to balance the needs and rights of the residents with the needs and rights of the workers (Eckert et al., 2009). Our research builds on this tradition. We found that residents’ desire to tease, flirt, or even act inappropriately toward staff were not routinely restricted. Instead, sexual words and actions were contextualized based on resident and worker characteristics and the behavior. Staff members refused to engage residents, redirected them, or reframed the words and gestures to get the job done and go about their workday. Yet sometimes, the behaviors got out of hand, and staff reported the behavior to administrators either to protect themselves or out of concern for the residents. In these cases, the administrators stepped in—sanctioning the residents, sometimes moving them, calling their families, and in extreme cases medicating them or discharging them from the facility.

Characteristics of the workers and residents are important to understanding how sexually inappropriate behavior was perceived and how workers responded to the behavior. When residents were perceived as vulnerable, predominately as having dementia, the workers were more likely to excuse or dismiss their behavior. This is similar to how nurses minimize inappropriate behavior from patients they perceive as vulnerable (Huebner, 2008; Ruchti, 2012). In addition, workers, who were more vulnerable by being younger or less experienced, were more likely to be outraged by sexually inappropriate words or action and to respond by reporting the behavior to their supervisor. Over time, these workers learned to control all but the most egregious behavior on their own or with the assistance of co-workers (Blackstone et al., 2014).

Our findings build on existing research on sexual harassment in health care settings. Similar to nurses in prior research, AL workers believed it was their responsibility to negotiate sexually inappropriate behavior in sensitive and professional manner to get the job done (Deery et al., 2011; Huebner, 2008; Ruchti, 2012). Although responses to sexual harassment varied, AL workers reported it to managers only when the behavior was egregious or perceived as intentional. Similar to other marginalized workers performing the dirty work of caregiving (Jervis, 2001; Stacey, 2005), AL workers distanced themselves from uncomfortable situations and took pride in their ability to get the difficult job done. Although this may be a useful coping strategy for individual workers, it reinforced the belief that the burden managing inappropriate sexual contact remains on the individual worker (Madison & Minichiello, 2004).

Implications for Policy and Practice

This research provides valuable lessons for owners and administrators in the AL industry. First, there is a need to design and implement policies about sexual harassment that include resident–staff harassment (Bentrott & Margrett, 2011). In most of the facilities we studied, administrators and staff could cite a policy of sexual harassment. But these policies were focused exclusively on worker–worker or supervisor–worker harassment and did not address inappropriate behavior from residents. Such a policy will facilitate worker rights and prevent misunderstandings.

Second, AL facilities need to do a better job providing training for staff regarding managing and reporting inappropriate language and behavior. In our research, workers learned how to get the job done from experience and working with peers. Individual characteristics of workers and residents and the intimate care relationships often contextualized how sexual harassment is perceived. Training, particularly for new and less tenured staff, can help create an environment that is a safe and welcoming space for the workers as well as the residents. Furthermore, administrators and managers need to be aware that these incidents may result in long-term emotional or stress outcomes for workers to better provide support for their employees (Rippon, 2000). By acknowledging and addressing the micro-aggressions of sexually inappropriate behavior, AL managers could address issues of burnout and retention for DCWs.

Finally, we believe that it is important to recognize that AL residents still have sexual needs. These sexual needs should be acknowledged as part of care planning. This includes training staff about residents’ sexual needs (Cornelison & Doll, 2013; Doll, 2012) and designing facilities in ways that provide private and safe space for intimate encounters (Bentrott & Margrett, 2011).

Implications for Future Research

This research was exploratory and aims to understand how sexually inappropriate behavior is negotiated in AL. Future research needs to test our conceptual model on a larger sample. Our sample of 49 workers and six administrators provides insight into the complexity of managing these situations, but a larger quantitative sample could tease out how residents’ sexually inappropriate behavior is experienced across different groups of workers. Furthermore, future research should examine whether the experience of sexual harassment is similar across care workers in different environments including home health and skilled nursing.

In addition, larger survey research could address how sexual harassment impacts worker satisfaction and mental health, absenteeism, and worker turnover. Existing research in AL has examined other dimensions of workplace stress but has not included the impact of sexual harassment (Ball et al., 2009; Kurowski, Boyer, & Punnett, 2015). The stresses of multiple minor incidents of sexual harassment were often invisible both to administrators and to workers themselves. For the most marginalized workers who performed the dirty work of AL while maintaining close emotional ties with residents, these words and actions wore down some DCWs. Future research should explore how sexual harassment influences worker satisfaction and turnover in AL.

Biographies

Elisabeth O. Burgess, PhD, is an associate professor of gerontology and sociology and director of the Gerontology Institute at Georgia State University in Atlanta. Her research interests include sexuality and intimacy over the life course, attitudes about age and older adults, and aging families.

Christina Barmon, MPH, is a doctoral candidate in sociology at Georgia State University where she is also earning a certificate in gerontology. She received her master’s degree in public health from Emory University. Her research focuses on sexuality and aging with an emphasis on the social construction of sex, health, and aging.

James R. Moorhead Jr., MA, recently received his master’s degree in gerontology Institute from Georgia State University. He works as Aging Services Coordinator with the Georgia Department of Human Services, Division of Aging Services. His research interests include lesbian, gay, bisexual, and transgender (LGBT) aging and cultural competency training.

Molly M. Perkins, PhD, is an assistant professor with Emory Division of General and Geriatric Medicine in the Emory University School of Medicine and is the Atlanta site Director for Research for the Birmingham/Atlanta VA Geriatric Research, Education, and Clinical Center (GRECC). Recent research focuses on social and behavioral aspects of chronic disease management, including palliative care.

Alexis A. Bender, PhD, is the chief of Field Investigations and Evaluation for the Army Public Health Center (Provisional), Behavioral and Social Health Outcomes Program. She received her doctorate in sociology with a certificate in gerontology from Georgia State University. Her research interests include disability, trauma, and life course transitions; military behavioral health; and sexuality over the life course.