Sexual Harassment Experience, Coping, and Awareness Among Nurses Working in Small- and Medium-Sized Hospitals in South Korea

Abstract

Introduction

Although over 60% of Korean acute care hospitals are small- or medium-sized, their ability to address sexual harassment may differ from larger hospitals due to differences in resources, policies, and organizational culture.

Objective

This study aims to identify sexual harassment experience, coping, and awareness among nurses working in small- and medium-sized hospitals.

Methods

This is a descriptive cross-sectional study that collected data from 462 nurses working in nine small- and medium-sized acute care hospitals in two cities in Korea. The study utilized self-report questionnaires, including the coping with sexual harassment questionnaire, perception of sexual, and experience of sexual harassment. Data were analyzed using descriptive statistics, t-tests, and one-way analysis of variance.

Results

Most nurses receive sexual harassment prevention education in the workplace every year, but only 77% of them are accurately aware of sexual harassment behavior. Among the types of sexual harassment experienced by the participants, verbal sexual harassment was the most common. Only 192 out of 462 nurses responded to the timing of their sexual harassment experience. Of those, more than 50% reported experiencing sexual harassment within the first year of employment and over 80% within 3 years. The most common perpetrators of sexual harassment were patients, followed by doctors. The more times the nurses received sexual harassment prevention education, the better they were at coping with sexual harassment.

Conclusion

To prevent sexual harassment in the workplace, training content should be tailored because attitudes and perceptions vary based on the perpetrator's characteristics. This ensures relevance, addresses risks, and clarifies legal responsibilities. To create a healthy and safe working environment for nurses, institutions and managers should implement methods to raise awareness of sexual harassment. This may include providing anonymous hotlines, online reporting systems, regular audits, and establishing anonymous peer counseling platforms.

Introduction

Sexual harassment in the workplace is a widely discussed topic and one deserving of critical examination. Workplace sexual harassment is defined as any unwelcome sex-related behavior that occurs in the workplace and is perceived as offensive or threatening to one's well-being (Fitzgerald et al., 1995). This topic is often avoided due to the social stigma associated with sexual harassment, but it has gained international attention as many women have taken to social media to share their experiences of sexual harassment (Landin et al., 2020).

Medical environments have not escaped the reach of this societal ill. The #MeToo movement and the #EndNurseAbuse campaign have brought attention to the prevalence of sexual harassment among healthcare professionals. It is important to create safe and supportive environments for nurses, end abuse, and promote health (ANA, 2019; Jenner et al., 2022). The prevalence of sexual harassment varies across countries due to cultural, economic, and educational factors, as well as differences in work environments and study methodologies (Adams et al., 2019; Lu et al., 2020). In particular, female nurses are significantly more likely to experience workplace sexual harassment than other healthcare workers (Adams et al., 2019; Landin et al., 2020). A previous study (Lu et al., 2020) found that female nurses accounted for 83.87% of the 32,970 participants in 25 studies, and among them, nurses reported an incidence of sexual harassment of 12.6%–95.6% in the past 12 months and 53.4% over their nursing careers (Bruschini et al., 2023; Lu et al., 2020). In South Korea, it is estimated that 10.6% of all clinical nurses had experienced sexual violence, such as sexual harassment and sexual abuse (Ministry of Health and Welfare, 2018). Workplace sexual harassment is a form of workplace violence that can negatively impact the psychological and physiological well-being of nurses, as well as their work environment, and further jeopardize patient safety (Kahsay et al., 2020; Maghraby et al., 2020; Varghese et al., 2022). Therefore, it is necessary to investigate nurses’ experiences, perceptions, and responses to sexual harassment in various settings and contexts.

Review of Literature

Workplace sexual harassment is a significant global healthcare issue that is rooted in unjust cultures, hierarchical structures, and gender inequality. Addressing this issue is crucial to protecting nurses and maintaining a healthy work environment (Zeighami et al., 2022). Workplace sexual harassment is not perpetrated accidentally but is rather an intentional act (Adams et al., 2019) that has a variety of attributes, ranging from verbal abuse to unwanted physical attacks (Gabay & Shafran Tikva, 2020; Maghraby et al., 2020; Zeng et al., 2020). Although sexual harassment is illegal, the legal and social understanding of sexual harassment varies by culture. In South Korea, all institutions, including schools, agencies, and hospitals, must provide sexual violence prevention education once a year for its employees, and employees are obliged to attend this training (Ministry of Employment and Labor, 2021). Nevertheless, Korean clinical nurses are exposed to verbal abuse, assault, and sexual harassment as they usually work shifts and in limited spaces.

Workplace sexual harassment can be perpetrated against nurses by coworkers, supervisors, doctors, and others, including inappropriate touching, sexual jokes, unwelcome advances, or spreading sexual rumors (Kim & Shin, 2023; Mohammed et al., 2023). In addition, nurses frequently spend more time with patients and perform tasks that involve close physical contact. They are often subjected to persistent sexual harassment by patients, including inappropriate comments, sexual advances, inappropriate gestures, leering, and unwanted physical contact (Bruschini et al., 2023; Gabay & Shafran Tikva, 2020). Sexual harassment in the workplace like this has been shown to have negative health effects on nurses, including fear, workplace aggression, and physical problems such as headaches, gastrointestinal disorders, and weight changes. Additionally, emotional problems such as shame, embarrassment, and humiliation, as well as psychological problems such as loss of confidence, lethargy, and social problems such as isolation and public shunning, have been reported (Gabay & Shafran Tikva, 2020; Kahsay et al., 2020). However, nurses who have experienced sexual harassment at work tend to be ashamed of what they have experienced and often try to hide the fact that they have been sexually harassed due to fear of retaliation by the perpetrator and fear that they will not be believed or receive assistance if they do inform the people around them about what has happened (Kim & Shin, 2023; Mohammed et al., 2023; Yoo et al., 2020).

After such an experience, victims no longer consider their workplace a safe environment and eventually their motivation, task performance, and quality of life decrease (Gabay & Shafran Tikva, 2020; Maghraby et al., 2020; Zeng et al., 2020). Nurses spend most of their day caring for patients; therefore, their working environment can have a direct impact on patient safety and quality of care (Varghese et al., 2022). However, despite workplace sexual harassment of nurses being a significant issue in the medical environment, it has not received sufficient attention (Draucker, 2019). To maintain a healthy working atmosphere and protect nurses from workplace sexual harassment, it is necessary to conduct repeated studies in various settings to understand its prevalence, contributing factors, and the effect on the healthcare system and practitioners in the nursing profession (Varghese et al., 2022).

In Korea, more than 60% of hospitals are classified as small- and medium-sized acute care hospitals (Korean Statistical Information Service, 2022). To ensure that hospitals have adequate staffing to properly care for patients, they are categorized based on the ratio of nurses to the average number of patients hospitalized every 3 months. The ratio in the first class is 1:3 or less, but it varies greatly by region, and there are insufficient nursing personnel up to nine grades of deviation (Health Insurance Review and Assessment Service, 2023). Nurses work either the second or third shift depending on the hospital's situation. Most newly graduated nurses undergo 1–3 months of training with a preceptor nurse before being assigned independent patient care based on their competencies (Kim, 2023).

Small- and medium-sized hospitals may respond differently to sexual harassment compared with larger hospitals due to variations in resources, policies, organizational culture, and oversight structures. They may not be equipped to effectively address incidents of violence, including sexual harassment, due to a lack of resources such as human resources departments, legal departments, and employee assistance programs (Jung et al., 2021). They may also lack formalized policies and rely more heavily on external resources (Bae, 2021). Organizations with informal cultures may be less aware of and respond inappropriately to harassment issues, rather than prioritizing diversity and equity (Jung et al., 2021; Kim et al., 2022). Additionally, oversight mechanisms may be less likely to respond to harassment, including sexual harassment allegations, due to less scrutiny from the public and media (Bae, 2021).

As described above, the attention of small- and medium-sized hospitals is required to implement policies, education, and support mechanisms to effectively prevent and resolve sexual harassment in the workplace. These include establishing clear reporting procedures, education on recognizing and responding to sexual harassment in the workplace, respect for all kinds of sexual harassment, and creating a culture of zero tolerance (Bruschini et al., 2023). However, there has been little research conducted on the sexual harassment experienced by nurses working in small- and medium-sized hospitals. Therefore, it is imperative to examine the sexual harassment experience, coping, and awareness s of nurses working in these settings. Furthermore, this will provide fundamental data for relevant institutions and governments develop policies and effective measures to regulate the negative consequences of sexual harassment in the medical environment.

Methods

Study Design and Participants

This cross-sectional study aimed to identify sexual harassment experience, coping, and awareness among nurses working in small- and medium-sized hospitals. A convenience sample of 708 nurses working at nine small- and medium-sized hospitals (100–300 beds) were recruited from two large South Korean cities. Data were collected from January to June 2019. Inclusion criteria were as follows: (1) nurses who have at least 3 months of experience practicing nursing independently, providing direct and indirect patient care after completing a senior's training or education period, (2) nurses who are currently employed in a medium-sized hospital with more than 100 beds but less than 300 beds, and (3) those who understand the purpose of the study and are willing to participate in the study. Exclusion criteria were as follows: (1) nurses who do not have direct contact with doctors, patients, guardians, etc., such as managers of nursing departments and unit managers, and (2) nurses who work in university hospitals or large medical centers and long-term care hospitals with more than 300 beds.

The sample size for computation of a test power (1−β) of 0.95 with an effect size of 0.20 and alpha of 0.05 was 314 (Cohen, 1988). Out of a total of 560 questionnaire, 487 (response rate of 86.9%) were returned. After excluding those with missing values, a total of 462 eligible participants were included in the study (response rate of 82.5%).

Materials

The Korean version of the questionnaire comprised four sections: general and clinical characteristics, sexual harassment coping, sexual harassment awareness, and experiences of sexual harassment. Participants in this study took approximately 15 min to complete the survey that comprised 44 questions of four sections. All the tools used in this study were utilized with the respective developers’ permission. Before the questionnaire was sent to the participants, we consulted with three qualified experts (one nursing professor and two nursing managers of small- and medium-sized hospitals) to verify the suitability of the items in the questionnaire.

General and clinical characteristics were gender, age, total career, current department, work type, and prevention of sexual harassment education.

Sexual Harassment Coping

Coping with sexual harassment involves internally focused and externally focused responses. Internally focused responses include endurance, detachment, denial, relabeling, and self-blame, while externally focused responses include avoidance, appeasement, confrontation, social support, and institutional relief (Magley, 2002). In this study, the Coping Harassment Questionnaire developed by Magley (2002) and adapted into a Korean version by Uhm and Jung (2018) was used to measure participants’ coping responses. It consisted of 10 questions, and each question was measured on a five-point Likert scale ranging from 1 = not at all to 5 = very much. The higher the score, the more active the participants’ coping strategy was. The Cronbach's α in the study by Uhm and Jung (2018) was .71 and Cronbach's α was .92 in this study.

Sexual Harassment Awareness (Recognition)

This assessment tool was developed at the Seoul National University Human Rights Center (2014) and consisted of 10 items. Responses were divided into three categories (yes/no/do not know) and coded as follows: yes = 1, no = 0, and do not know = 0. The four questions in which the correct answer was “no” were converted in reverse. The total score range was between 0 and 10 points. A higher score indicated a greater level of sexual harassment awareness. The Cronbach's α in the study by Oh (2015) was .76 and Cronbach's α was .69 in this study.

Experience of Sexual Harassment

This scale was developed by Lim (2000). There were three subcategories of questions: visual sexual harassment (4), verbal sexual harassment (9), and physical sexual harassment (5). Responses were dichotomous (yes/no) and coded as yes = 1 and no = 0 with a total score range of between 0 and 18 points. A higher score indicated that the participant had experienced a greater level of sexual harassment. The Cronbach's α was .89 in the study by Kim (2015) and .92 in this study.

Data Analysis

Data were analyzed using IBM SPSS Statistics for Windows, version WIN 21.0 (IBM Corp., Armonk, NY, USA). The participants’ general and clinical characteristics, sexual harassment coping, sexual harassment awareness (recognition), and experience of sexual harassment were analyzed with descriptive statistics. The difference in sexual harassment coping according to the participants’ general and clinical characteristics was analyzed using the t-test, ANOVA, and post-hoc analysis using the Scheffé test. The sexual harassment coping was analyzed using mean and standard deviation. Psychometric reliability was calculated using Cronbach's α.

Ethical Considerations

We followed the guidelines of the Declaration of Helsinki to ethically protect study participants. This study was approved by the Institutional Review Board of D University (IRB approval number: 1040647-201806-HR-024-03). Prior to conducting the study, the participants provided written consent. In addition, the participants were informed that they could withdraw their consent at any time during the study and that personal information would be coded to ensure anonymity.

Results

The general characteristics of the study participants are presented in Table 1. The mean age was 32.15 (±7.52) years, and 50.3% of the participants were under 30 years old. The average clinical career was 8.14 years, and 40% of the participants had been practicing as nurses for less than 5 years. A figure of 64.7% worked on the wards of their hospital; 24.7% worked in special departments such as emergency departments and intensive care units; 10.6% worked in examination rooms, etc.; and 61.3% worked three shifts. Approximately 84.2% of the participants had received sexual harassment prevention education more than once a year.

Table 1.

Differences in Sexual Harassment Coping According to General Characteristics of Study Participants (N = 462).

Variables	Categories	N	%	Sexual harassment coping
				Totally coping responses				Externally coping responses				Internally coping responses
				mean	SD	t/F	p	mean	SD	t/F	p	mean	SD	t/F	p
Gender	Male	18	3.9	3.07	0.59	−2.32	.020	3.40	0.68	−2.28	.023	2.74	0.68	−1.56	.119
	Female	444	96.1	3.35	0.49			3.72	0.58			2.99	0.66
Age	25 lower	101	21.9	3.25	0.38	2.38	.045	3.64	0.46	1.39	.224	2.87	0.59	1.98	.079
(in years)	26–30	131	28.4	3.32	0.45			3.71	0.53			2.92	0.62
	31–35	90	19.5	3.47	0.59			3.81	0.68			3.12	0.73
	36–40	70	15.2	3.33	0.47			3.62	0.64			3.06	0.59
	41–45	44	9.5	3.30	0.56			3.71	0.71			2.9	0.71
	45 over	26	5.6	3.46	0.60			3.87	0.55			3.09	0.86
	Mean (SD)	32.15 (7.52)
Total career	5 lower	185	40.0	3.29	0.43	1.48	.228	3.67	0.53	0.86	.420	2.93	0.61	1.33	.265
(in years)	6–10	130	28.1	3.35	0.52			3.75	0.61			2.98	0.67
	11 over	147	31.8	3.38	0.55			3.72	0.64			3.05	0.72
	Mean (SD)	8.41 (6.80)
Current	ward	299	64.7	3.33	0.49	0.35	.702	3.68	0.61	0.69	.502	2.99	0.66	0.71	.493
department	special unit	114	24.7	3.33	0.45			3.74	0.54			2.91	0.65
	etc.	49	10.6	3.39	0.62			3.77	0.57			3.03	0.69
Work style	daytime a	116	25.1	3.34	0.53	5.94	.001	3.73	0.69	2.28	.078	2.99	0.66	5.88	.001
	3 shift b	283	61.3	3.39	0.48	b > a,d		3.74	0.55			3.05	0.64	a,b > d
	2 shift c	25	5.4	3.09	0.28			3.48	0.40			2.70	0.52
	Etc. d	38	8.2	3.10	0.56			3.56	0.61			2.64	0.74
	none	73	15.8	3.20	0.38	3.81	.010	3.65	0.47	1.16	.322	2.77	0.55	3.97	.008
	1	160	34.6	3.32	0.49			3.66	0.59			2.95	0.64
	2–3	136	29.4	3.44	0.51			3.78	0.61			3.10	0.66
	4 higher	93	20.1	3.34	0.55			3.72	0.62			3.02	0.72
Sexual harassment coping	Mean (SD)	3.34 (0.50)

The mean score of the sexual harassment coping was 3.34 (±0.50), and we found differences in the manner in which the participants coped with sexual harassment by gender, age, work style, and the number of times they had received sexual harassment prevention education. In particular, three shift workers were better at coping with sexual harassment than full-time or two-shift workers. In addition, in the subscale, internally focused responses differed by work style and sexual harassment prevention education, and externally focused responses differed by gender (Table 1).

The participant's awareness of what behavior constitutes sexual harassment is presented in Table 2. The average rate of correct answers was 77.6% of the participants. Only 35.5% of the participants were aware that “Sexual harassment is a form of gender discrimination.” The other questions with the lowest percentage of correct answers were: “If you are watching the pornographic site alone in your office and someone else accidentally sees it, this can also be sexual harassment,” “The contents of counseling about sexual harassment are confidential,” and “If the victim who was sexually harassed did not clearly express his rejection, he/she could not take issue with his/her damage as sexual harassment” with 54.5%, 66.2%, and 78.6%, respectively (Table 2).

Table 2.

Awareness of What Constitutes Sexual Harassment (N = 462).

Categories (correct answer)	Correct answer ratio
	N	%
1. Sexual harassment is a social issue and must be resolved on a personal level (no)	422	91.3
2. The criteria for judging sexual harassment are whether the perpetrator was intended to commit rather than how the victim was affected (no)	384	83.1
3. The contents of counseling about sexual harassment are confidential (yes)	306	66.2
4. Sexual harassment is a form of gender discrimination (yes)	164	35.5
5. If you are watching the pornographic site alone in your office and someone else accidentally sees it, this can also be sexual harassment (yes)	252	54.5
6. Sexual jokes can also constitute sexual harassment (yes)	448	97.0
7. In order for sexual harassment to be established, physical body contact must be accompanied (no)	432	93.5
8. Men or women can get legal help under the law if they have been sexually harassed (yes)	387	83.8
9. If the victim who was sexually harassed did not clearly express his rejection, he/she could not take issue with his/her damage as sexual harassment (no)	363	78.6
10. The heads and users of public institutions are legally obligated to take measures to prevent sexual harassment (yes)	426	92.2
Mean of ratio of answers		77.6

The characteristics of sexual harassment experience were presented based on the number of respondents among 462 participants (Table 3). Among the 230 respondents, most of the perpetrators of sexual harassment were patients and then doctors comprising 58.08% (133) and 18.78% (43), respectively. Among 228 respondents, the most common place for sexual harassment to occur was in a public place, such as a hospital room or waiting room 44.74% (102), followed by a company dinner 22.37% (51). Out of 192 respondents, about 80.73% (155) of the participants experienced sexual harassment within 3 years of joining the hospital and 57.29% (110) experienced sexual harassment within 1 year. Out of 223 respondents, approximately 51.57% (115) experienced sexual harassment once or twice a year. Also, 48.74% (58) of 119 respondents found that coworkers were most likely to help the participants if they found out that the participant had been a victim of sexual harassment. Among 214 respondents, the most common reasons given by the participants for not responding actively to sexual harassment were that “I’m not sure it's worth the effort” (39.25%) and “I didn’t know what to do” (23.83%). Approximately 16.36% of the participants answered “I’m afraid that relationship will get tough” in connection with their relationship with the perpetrators.

Table 3.

Characteristics of Sexual Harassment Experience (N = 462).

Variables	Categories	N	%	Respondent a
				n	%
Perpetrator	Doctor	43	18.78	230	49.78
	Patient	133	58.08
	Patient's relatives	15	6.55
	Superiors	17	7.42
	Coworker	12	4.81
	Other	10	4.37
Experience place	A public place like a waiting room	102	44.74	228	49.35
	Enclosed place	22	9.65
	Company dinner	51	22.37
	An outside place like a picnic	3	1.32
	Others	50	21.93
Experience time	Within 6 months	38	19.79	192	41.56
(after joining the company)	Within a year	72	37.50
	Within 2–3 years	45	23.44
	After 3 years	23	11.98
	From time to time	14	7.29
The frequency of experience	Almost every day	3	1.35	223	48.27
	1–2 times a week	11	4.93
	1–2 times a month	37	16.59
	1–2 times a year	115	51.57
	Other	57	25.56
The person who helped	Doctor	5	4.20	119	25.76
	Patient	4	3.36
	Patient's relatives	1	0.84
	Superiors	46	38.66
	Coworker	58	48.74
	Others	5	4.20
Reasons for not responding actively	I’m not sure it's worth the effort	84	39.25	214	46.32
	I didn’t know what to do	51	23.83
	I was embarrassed	1	0.47
	I feel like I’m going to get retaliated	5	2.34
	Because there is no evidence	10	4.67
	I'm afraid that relationships will get tough	35	16.36
	I didn’t feel bad	1	0.47
	Etc.	27	12.62

^a Analyze only the respondents to the questions.

The types of sexual harassment experienced by the participants are presented in Table 4. The types of sexual harassment were divided into verbal, visual, and physical sexual harassment. In the visual sexual harassment category, 39.8% of the participants advised that they had experienced a perpetrator “Looking up and down at me, intentionally exposing his body part, or touching by himself” and 22.7% had experienced this directly. Other common visual sexual harassment experiences included “Exposing or touching part of the body related to genital organs” and “Displays or sends sexist or obscene articles, images, videos, etc. in the workspace,” and these were experienced by 27.3% and 26.0% of the participants, respectively (Table 4).

Table 4.

Types of Sexual Harassment Experienced by the Participants ^a (N = 462).

Categories	Pattern of sexual harassment	Yes		Indirect experience		Direct experience
		n	%	n	%	n	%
Visual	1. Displays or sends sexist or obscene articles, images, videos, etc. in the workspace	120	26.0	84	18.2	36	7.8
	2. Exposing or touching part of the body related to genital organs	126	27.3	62	13.4	64	13.9
	3. Looking up and down at me, exposing his body part, or touching himself	184	39.8	79	17.1	105	22.7
	4. Behavior reminiscent of sexual intercourse	77	16.7	22	4.8	55	11.9
Verbal	5. Derogatory remarks and curses against women	261	56.5	119	25.8	142	30.7
	6. Talking about sexual stories, making obscene rumors or calls, etc.	159	34.4	86	18.6	73	15.8
	7. Kept asking to meet, ignoring what I didn’t want	71	15.4	40	8.7	31	6.7
	8. Spreading sexual scandals	156	33.8	81	17.5	75	16.2
	9. Evaluating appearance, clothing, body, etc. and seeing it as a grade target	59	12.8	41	8.9	18	3.9
	10. Coffee entertainment, errands, etc., and that's what women say it's better to do	142	30.7	83	18.0	59	12.8
	11. The stories that describe the genitals of woman or man	84	18.2	54	11.7	30	6.5
	12. The sarcastic or ridicule regarding menstruation	80	17.3	54	11.7	26	5.6
	13. Speaking out about his private life or sexual experience	84	18.2	52	11.3	32	6.9
Physical	14. The words and actions that seemed to require sexual service	161	34.8	68	14.7	93	20.1
	15. Forced me to have sex or tried it	36	7.8	26	5.6	10	2.2
	16. Trying to seduce to a secret place that I did not want	50	10.8	27	5.8	23	5.0
	17. Intentionally made or tried to physical contact me	111	24.0	45	9.7	66	14.3
	18. Forced to attend or attend sexual shameful dinners and hospitality	56	12.1	35	7.6	21	4.5

^a We only included the types of sexual harassment that were provided in the participants’ responses to items from the questionnaire.

In the verbal sexual harassment category, 56.5% of the participants advised that they had experienced “Derogatory remarks and curses against women,” and 30.7% had experienced this directly. Additional verbal sexual harassment experiences included “Talking about sexual stories, making obscene rumors or calls, etc.,” “Spreading sexual scandals,” and “Coffee entertainment, errands, etc., and that's what women say it's better to do,” and these were experienced by 34.4%, 33.8%, and 30.7% of the participants, respectively (Table 4). In the physical sexual harassment category, 34.8% of the participants experienced “The words and actions that seemed to require sexual service” and 20.1% had experienced it directly. Another common physical sexual harassment experience faced by the participants was when a perpetrator “Intentionally made or tried to make physical contact me” as this was experienced by 24% of the participants. “Forced me to have sex or tried it” was experienced by 7.8% of the participants (Table 4).

Discussion

Although the sexual harassment of nurses is considered an increasingly important occupational safety and health issue, it still remains largely taboo and goes unreported. This study investigated how nurses cope with sexual harassment, nurses’ awareness as to what behavior constitutes sexual harassment, and nurses’ sexual harassment experiences in South Korean small- and medium-sized hospitals. Most of the participants in our study received sexual harassment prevention education every year, but only 77% were accurately aware of what behavior constitutes sexual harassment. Among the types of sexual harassment experienced by the participants, verbal sexual harassment was the most common. The most common perpetrators of sexual harassment were patients, followed by doctors. The more times per year the participants received sexual harassment prevention education, the better they were at coping with sexual harassment.

Coping with Sexual Harassment

It was found that there were differences in the way the participants coped with sexual harassment according to their gender, age, work style, and the number of times they underwent sexual harassment preventive education per year. These differences may be attributed to the difference in values and perspectives on sex and gender roles in countries like Sri Lanka, Germany, sub-Saharan Africa, and Egypt, according to the sociocultural backgrounds, including the age and gender roles of the time (Adams et al., 2019; Adler et al., 2021; Landin et al., 2020; Maghraby et al., 2020).

It was found that the three shift workers coped better with sexual harassment than the full-time or two-shift workers. This is similar to the findings in previous studies (Maghraby et al., 2020; Yoo et al., 2020). Full-time or two-shift nurses may have more contact with the perpetrator depending on their hours of work and may become evasive or numb to dealing with sexual harassment. Draucker (2019) reported that victims of sexual harassment engage in a wide variety of passive and active coping strategies, such as leaving the scene where the harassment occurred, avoiding the perpetrator, or avoiding the department in which the harassment occurred. It has also been found that the victims of sexual harassment confided in or obtained support from friends or family as well as colleagues or coworkers. This should educate nurses with respect to coping strategies with sexual harassment, focusing on an open, multidisciplinary environment where they can talk freely and safely (Jenner et al., 2022).

It was found that 84.2% of the participants received sexual harassment prevention education more than once a year. This is similar to the findings of previous studies (Lu et al., 2020). In South Korea, in order to create a safe working environment in 2017, employees and employers of all institutions were required to receive sexual harassment prevention education at least once a year (Ministry of Employment and Labor, 2021). Accordingly, the rate of sexual harassment prevention education undergone by our participants would have been high. In addition, since 2020, the Korea Nursing Association has been conducting sexual harassment prevention education for all nurses online, but the same is not subdivided according to work characteristics or work experience.

Awareness of What Behavior Constitutes Sexual Harassment

In this study, the participants’ awareness of what constitutes sexual harassment was correct in less than 77.6% of the items, and these findings are similar to the results of previous studies (Uhm & Jung, 2018). Due to the rigid and authoritative workplace culture of medical organizations, nurses who are the victims of sexual harassment often do nothing, pretending that the experience did not happen (Lim & Kim, 2021; Ministry of Health and Welfare, 2018). Against this sociocultural background, nurses’ awareness of what constitutes sexual harassment would have been affected. Efforts are needed to improve nurses’ awareness of what behavior constitutes sexual harassment and to ensure that they experience a safe working environment. This requires the implement policies, education, and support mechanisms to effectively prevent and resolve sexual harassment in the workplace (Bruschini et al., 2023).

Experiences of Sexual Harassment

Characteristics of sexual harassment experience. Consistent with the results of previous studies (Zeighami et al., 2022), most of the sexual harassment perpetrators were patients. Nurses’ emotional well-being is crucial as they're expected to empathize with patients. However, this emotional labor can blur the boundaries between work and gender roles, particularly when patients are identified as frequent perpetrators (Adams et al., 2019). Such sexual harassment undermines nurses’ professionalism, objectifies them, and can hinder their ability to provide quality care, potentially jeopardizing patient safety (Gabay & Shafran Tikva, 2020).

In this study, the results of when and where the sexual harassment was experienced by nurses were similar to the findings of previous studies (Adler et al., 2021; Maghraby et al., 2020; Seo & Kim, 2019). As sexual harassment can occur in other forms of bullying depending on the workplace culture within an organization, sexual harassment prevention measures suitable for the specific working environment are needed (Jenner et al., 2022). In particular, only 192 out of 462 nurses responded about sexual harassment time, but 57% of the respondents said it happened within their first year at the company. The fact that nurses are subjected to sexual harassment during the process of adapting to a new organizational culture is of great significance. It is important to sexual harassment prevention education to nurses within their first year of employment and establishing an organizational culture early on to help them effectively manage instances of sexual harassment (Park et al., 2019).

It was found that the most common places where sexual harassment occurred were “A public place such as a hospital room or a waiting room” and “Company dinner,” but our questions did not examine how many people were present at the time the harassment took place. The results differed from previous studies (Kheir et al., 2023), which found that sexual harassment occurred in rooms (doctor, nursing, examination), corridors, stairs, and elevators. So it is necessary to investigate this aspect in future studies. Efforts should be made to create environments that are less conducive to harassment, ensuring workplaces are safe and supportive for all nurses.

Since the cultural background of organizations in South Korea is a relationship-oriented culture, a company dinner is considered to play an important role in the development of a positive organizational culture (Choi & Kim, 2023). Company dinners are not held once off, but rather, they are held frequently. This is likely to cause problems for victims, and it will be necessary to regulate the method, place, and time of company dinners in the future.

In this study, most of the individuals who assisted the participants after they had experienced sexual harassment were colleagues, not superiors. This may be due to the fact that colleagues have had similar experiences, but this aspect was not investigated in our study. It may also be due to the fact that participants share their daily lives with their colleagues and feel more comfortable with a colleague than a supervisor (Draucker, 2019). In this study, when the participants were subjected to sexual harassment, the reason given for why they did not respond actively was similar to the results of previous studies (Draucker, 2019; Jo, 2017; Seo & Kim, 2019). Active responses to sexual harassment are essential, and these include informal social support, informal organizational support, and formal organizational and legal support (Worke et al., 2021). However, in Korea's Confucian culture (Jo, 2017), nurses have difficulty actively coping with the authoritative workplace culture of medical organizations, lack of management skills, lack of complaint procedures, and social acceptance/support (Worke et al., 2021). According to a 2017 study conducted by Jo (2017), reports of violence, such as sexual harassment, were less than 10%. However, nurses expect their organization to exhibit a resolute commitment to addressing sexual harassment. Therefore, hospitals must devise effective strategies that consider both personal and systemic factors when addressing these issues (Gupta, 2021; Jenner et al., 2022).

Types of Sexual Harassment

In this study, each participant had at least one experience of sexual harassment, whether it was visual, verbal, or physical harassment, and they experienced it either directly or indirectly. Verbal sexual harassment was most commonly experienced by the participants, followed by visual and physical sexual harassment. These findings are similar to the results of previous studies conducted (Kahsay et al., 2020; Landin et al., 2020; Maghraby et al., 2020). Sexual harassment has a number of negative effects on nurses, including adverse mental and physical health outcomes, damaging financial consequences, and may even harm opportunities to advance their careers (Maghraby et al., 2020). Although sexual harassment is gaining importance as an occupational health and safety issue which needs to be dealt with by the wider medical community, the issue of sexual harassment perpetrated against nurses has still not yet received sufficient public attention (Kahsay et al., 2020). To address this issue, it is recommended to develop and implement policies focused on social interest, improving education for the public, holding perpetrators accountable, and prevention (Adams et al., 2019).

The findings suggest that the harm caused by sexual harassment to nurses in small- and medium-sized hospitals has not been fully investigated, and the negative health and social consequences associated with it are not well understood. Therefore, it is crucial to address sexual harassment among nurses as it is closely linked to the effective delivery of quality healthcare. Organizations must establish a culture that informs victims of appropriate responses, provides a safe work environment, and encourages open discussion of experiences without fear.

Strengths and Limitations

This study is meaningful in that it clarifies nurses’ perceptions of how they cope with sexual harassment and what behaviors correspond to sexual harassment in small- and medium-sized hospitals in South Korea. Nevertheless, this study has certain limitations. First, there may be difficulties in generalizing the results of the study as the sample population was extracted by convenience from nurses in small- and medium-sized hospitals. Since the content of sexual harassment was evaluated on a self-administered scale and nurses who perceived sexual harassment as a workplace issue had a higher response rate to the survey, the data from the participants may be biased. Third, it is possible that the responses regarding the experiences of sexual harassment are not 100% representative of real-life experiences and that the phenomena of sexual harassment of nurses by patients and relatives have different effects on the quality of care; therefore, the results of this study should be interpreted with caution.

Implications for Practice

This study contributed to current research on sexual harassment in a number of ways. First, it is important to recognize that attitudes and opinions about sexual harassment differ by gender and age. Consequently, sexual harassment training programs should vary in content, such as behavioral guidelines, depending on the characteristics of the workplace, the person in charge, the manager, and the nurse. Second, it is important to raise awareness and sensitivity of the prevalence of sexual harassment in healthcare institutions so that hospital managers can create a healthy and safe working environment for nurses. This requires support such as a centralized anonymous system and informal hotline reporting system, continuous audit and work environment evaluation, etc., where nurses can safely and easily report sexual harassment cases. It is also important to provide counseling programs for victims. Third, new nurses in hospitals should receive sexual harassment prevention training in the orientation program. The training content should specifically include guidelines for coping with situational sexual harassment. Fourth, the sexual harassment victims in this study received practical help primarily from their coworkers. In order to bring about changes in nurses’ coping behaviors and perceptions of sexual harassment, hospital administrators should consider using sexual harassment education methods such as simulations and role playing to conduct small group trainings where nurses can share their experiences and thoughts with each other (Addis & Snowdon, 2023). Finally, community and governmental organizations have a critical role to play in legislative efforts to prevent nurses from experiencing sexual harassment in the workplace. Hospital institutions should also be required to post posters about verbal and physical assault, including sexual harassment, in public places such as restrooms and corridors.

Conclusions

Most of the nurses in our study from small- and medium-sized hospitals in South Korea received annual sexual harassment prevention training, but only 77% correctly recognized sexual harassment. However, the more the participants received sexual harassment prevention education, the better their ability to deal with sexual harassment.

Based on these findings, it is necessary to review the appropriateness and effectiveness of training methods and content on sexual harassment awareness among nurses in small- and medium-sized hospitals. In addition, it is important to ensure that nurses perceive a healthy and safe working environment. Therefore, institutional administrators should work to implement methods such as centralized, anonymous, and informal hotline reporting systems that make it safe and easy to report cases of sexual harassment.