Iranian Nurses' Experiences with Sexual Harassment in Workplace: a Qualitative Study.

BACKGROUND: Sexual harassment has become a worldwide issue in recent years. Nursing, like other professions, is vulnerable to this type of harm. Sexual harassment impairs nurses' ability to provide comprehensive care, resulting in psychological discomfort, diminished work commitment, absenteeism, and job termination. The current study was carried out to investigate Iranian nurses' experiences with sexual harassment in the workplace.
MATERIALS AND METHODS: This qualitative study used conventional content analysis with a descriptive exploratory approach to investigate the experiences of Iranian nurses. Between September 2020 and April 2021, we conducted semi-structured and in-depth interviews with 22 employed nurses, recruited via a purposeful method. Age, sex, work experience, degree of education, marital status, and hospital and ward type were observed to acquire rich information.
RESULTS: The study's data produced 354 codes, 1 main category, 5 s categories, and 23 sub categories. The main category of nurses' sexual harassment in the workplace is divided into five categories: verbal, physical, visual, seduction, and cybersexual harassment. The most and least common types of harassment were verbal and cybersexual harassment, respectively. Nurse harassment was perpetrated by patients and their families, physicians, colleagues, and other hospital personnel.
CONCLUSION: According to the findings of this study, the majority of nurses have been subjected to sexual harassment in the workplace in various forms. Given the negative consequences of workplace harassment, managers and policymakers should develop guidelines in the areas of workplace ethics, legal accountability, and workplace safety. There is also a need to develop training programs for nurses to improve their coping skills. More quantitative and qualitative research in other healthcare groups is needed to confirm the findings of this study.

Background

Sexual harassment has become increasingly common in recent decades. Sexual harassment and gender discrimination have become commonplace in all professions, and healthcare workers have been no exception (von Gruenigen & Karlan, 2018). Sexual harassment is defined as repeated and unpleasant sexual behaviors that include verbal, physical, psychological, and visual types that are common in the workplace (Zeng et al., 2019) and are accompanied by humiliation, insults, or threats to the health of victims (Suhaila & Rampal, 2012). Sexual harassment is sexual coercion in order to have sexual advances and requests with someone against his or her will, and it occurs in an unequal power dynamic. Sexual harassment, according to Fitzgerald, is a behavior that includes three related but conceptually distinct dimensions: gender harassment, unwanted sexual attention, and sexual coercion (Fitzgerald et al., 1995). Gender harassment includes a variety of verbal, physical, and symbolic behaviors that suggest a hostile and insulting attitude toward women. Sexual remarks or gestures, dirty jokes, the display of sexual images, and gender-based behaviors, threats, or hostility are examples of such behaviors that are done with the intention of insulting women rather than expressing sexual or romantic desires (Page et al., 2016). Unwanted sexual attention refers to verbal and non-verbal behaviors that are undesirable, offensive, and one-sided. Unwanted sexual attention consists of sexual remarks, intentional touching, aggression, and insistence on informal communication that are perceived as unwanted, untrustworthy, and offensive by the recipient. Sexual coercion is defined as the use of social power to elicit sexual cooperation (Herrera et al., 2018).

Sexual harassment, according to studies, is widespread and varies by country. In a Malaysian study of public-sector managers, 43% of men and 47% of women said they had been sexually harassed in some way (Marican, 2000). Sexual harassment was reported by 5.6% of men and 28.1% of women in Korean emergency medical personnel (Yoo et al., 2019). Sexual harassment was prevalent in 1.8–34% of American students (Fedina et al., 2018) and 16.7% of Norwegian students (Sivertsen et al., 2019). In Asia, 21.6% of nurses are sexually harassed, compared to 16.2% in Europe, 22.4% in the Middle East, 38.7% in the UK (Spector et al., 2014), and 51.2% in Malaysia (Suhaila & Rampal, 2012). The findings of studies on the prevalence of sexual harassment cover a wide range. The reason for these differences is most likely due to differences in sampling method, tools used, and differences in social, cultural, and economic environments, and thus findings from one country cannot be generalized to other countries (Nielsen et al., 2017; Shi et al., 2017).

Sexual harassment in the workplace generates an atmosphere of fear and insecurity. Sexual harassment in the workplace must be handled since it increases victims’ fear and causes serious physical, psychological, and emotional difficulties (Apell et al., 2019; Koinis et al., 2019; Steiner & Wooldredge, 2015). Resignations, frequent absences, incompatibility with colleagues, leaving work, and deviant behaviors, as well as declines in energy, work efficiency, creativity, job satisfaction, and patient care quality, are all signs of extended and persistent workplace stress (Merkin & Shah, 2014).

Another important issue that emphasizes the importance of addressing sexual harassment in nurses is that many incidents of sexual harassment in the workplace go unreported for a variety of reasons, including cultural factors, negative consequences, peer pressure, and the victim’s unwillingness. Many victims believe that reporting an incident is pointless or, due to previous experience or a lack of knowledge of policies and guidelines, prefer to remain silent and refuse to report it (Chang & Cho, 2016). In addition, sexual harassment in the workplace is a topic that is frequently avoided due to social stigma, but it reached a tipping point in 2017 with the Me Too movement on social media and received international attention (Tollstern Landin et al., 2020). The experience of sexual harassment is essentially subjective and dependent on the cultural and socioeconomic context of the societies in which it occurs, and it appears that different types of sexual harassment have different meanings in different cultures (McCann, 2005). Women will face social stigma, humiliating statements, and discrimination if they act against the social roles assigned to them in a given culture. As a result, women in some countries avoid breaking traditional norms, and instead of fighting against sexually abusive behavior, they choose to ignore it in order to maintain their status as respectable women. This, in turn, reinforces sexual harassment as a socially acceptable practice (Merkin, 2012).

Since different countries have varied cultural traits, sexual harassment can take many different forms (McCann, 2005; Merkin, 2012). There is limited research on sexual harassment in nations with a religious cultural base, such as Iran. Because it is a taboo subject about which people are forbidden to speak, our understanding of sexual harassment in Iran is insufficient for us to effectively control and prevent it. Planning becomes more deliberate and efficient when nurses' experiences of sexual harassment are fully explored. As discussing sexual issues is taboo in Iran's socio-cultural context, victims are unable to freely express their feelings for reasons such as being labeled, ashamed, and stigmatized by the existing cultural context, and they believe that retelling the story will result in a higher level of stigma, notoriety, and guilt. As a result of the importance of sexual harassment and the scarcity of studies that have thoroughly investigated the phenomenon, this study was carried out to describe the experiences of Iranian nurses with sexual harassment.

Materials and Methods

Context

Iran is a country in Western Asia that is officially known as the Islamic Republic of Iran. Iran has a population of more than 83.5 million people. The Islamic Republic of Iran’s constitution states that Islam is the country’s official religion. Persian is the official language of this country. There are thirty-one provinces in the country. At least one Medical Science University in each province (MSU). These MSUs have two missions: to provide healthcare and to provide higher education. At least one full-time basic nursing program is offered at each MSU. Professional nursing in Iran is based on European countries’ professional nursing. In Iran, nursing is a university-based academic subject that educates nurses at three levels: bachelor’s, master’s, and doctoral. The first nursing school in Iran was created in 1916, and the quality of nursing education has improved with the foundation of the Ministry of Health and Medical Education in 1985 and the development of nursing colleges (Tabari Khomeiran & Deans, 2007).

Study Design and Setting

This qualitative study was conducted by means of conventional qualitative content analysis with a descriptive-exploratory approach. Content analysis is a qualitative method for analyzing written, verbal, or visual communication messages. The purpose of content analysis research is to obtain a concise and comprehensive description of the phenomena. According to Thyme et al., Graneheim, and Lundman, qualitative content analysis can be performed with varying degrees of interpretation. They claimed that there were manifest and latent messages in every text, and that both must be interpreted, although the depth and level of abstraction may differ (Graneheim & Lundman, 2004; Thyme et al., 2013). In this study, we attempted to analyze both the latent and manifest content. This study was conducted in Kerman, the largest city in southeastern Iran. Nurses from all hospitals associated with Kerman University of Medical Sciences were studied in this study (4 hospitals). In the emergency, intensive care, specialist, supra-specialized, and psychiatric departments, these institutions have around 1400 active beds. The researcher was directed to interview nurses in private hospitals after interviewing a number of nurses, some of whom had prior experience working in private hospitals. Three private hospitals’ nurses were also interviewed.

Sampling, Participant, and Data Collection

As no absolute rule determines the number of participants in qualitative research, sampling in our study continued until data saturation and the extraction of new information. After interviewing 22 participants, the current study reached saturation. Participants were chosen through purposeful sampling. Initially, interviews were conducted with nurses working in various wards of hospitals affiliated with Kerman University of Medical Sciences. The need to interview nurses in private hospitals was also identified as a result of the interview process. Therefore, interviews were conducted with a number of nurses working in private hospitals. The interviews were conducted with the participants’ permission and at predetermined times. Nurses with different and rich experience in the concept of research were interviewed in order to obtain rich and varied information. In addition, a variety of personal and occupational characteristics were chosen to provide a wide range of information, including gender, age, marital status, level of education, work experience, position, type of hospital (public, private, educational), and wards in which they had work experience. There were 18 female nurses, aged between 25 and 51 years, with work experience ranging from 2 to 28 years (Table 1). Participants were chosen based on a set of inclusion criteria. Nurses with a bachelor's degree or higher and clinical work experience were interviewed in this study. The first researcher conducted semi-structured, face-to-face individual interviews. Table 2 shows some of the questions that reflect participants' experiences with sexual harassment. The interviews lasted 30 to 100 min and were audio recorded before being transcribed verbatim. Sampling was performed from September 2020 to April 2021.

Table 1

Participants’ characteristics (N = 22)

Participants
Sex	Male	4
	Female	18
Age (years)	Minimum	25
	Maximum	51
Marital status	Single	7
	Married	12
	Divorced	3
Work experience (years)	Minimum	2
	Maximum	28
Education level	Bachelor’s degree	15
	Master’s degree	6
	PhD	1
Employment	Contract recruiters a	4
	Contract recruiters b	5
	Hired	13
Position	Nurse	14
	Head nurse	2
	Supervisor	3
	Faculty member	3
Type of hospital*	Educational/public	20
	Public/non-educational	1
	Private	9
Ward*	Emergency	11
	Medical	8
	ICU	7
	Operating room	6
	CCU	5
	General surgery	4
	Nursing management office	3
	Orthopedic	3
	Psychiatric	3
	Pediatrics	2
	Gastrointestinal	2
	Burn	1
	Dialysis	1

*Some participants had work experiences in different hospitals and wards

aIt is obligatory to work for government for 2 years at a lower rate of pay

bAnnually contracted with payment less than hired nurses

Table 2

Example of questions

Questions
1. What is your definition of sexual harassment in the workplace?
2. Could you please tell me about your sexual harassment experience in the workplace?
3. What types of sexual behavior have you observed and experienced in your workplace that have offended you?
4. What types of sexual behavior have you observed and experienced among your coworkers that have bothered you?

Data Analysis

The following concepts are important when performing conventional qualitative content analysis: unit of analysis, meaning unit, condensation, code, category, and theme. The unit of analysis is the foundation of qualitative content analysis. According to Graneheim and Lundman, the unit of analysis is an interview that is large enough to be considered as a whole but small enough to serve as a context for the meaning unit during the analysis process (Graneheim & Lundman, 2004). Each interview was treated as a separate unit of analysis in our research. The text was divided into meaning units after the unit of analysis was determined. Each meaning unit consists of words, sentences, or paragraphs that are related in terms of content and context. Table 3 contains examples in this regard. In the next step, the meaning units were condensed while maintaining the theme. The condensed meaning units were then labeled with a code and subcategories were created. The next step was to develop the categories that are central to qualitative content analysis. A category is a collection of codes with similar manifest levels. In our study, the main category of cases of sexual harassment in the workplace was obtained (Table 4). Although the analysis process was systematic, it was a reciprocal movement between the whole and the components of the text. Table 3 summarizes the analysis process for each text, and Table 4 summarizes all sub categories and categories. The analysis process continued from September 2020 to May 2021.

Table 3

Example of qualitative content analysis process

Meaning unit	Condensation	Code	Subcategories	Categories	Main category
The emergency department was extremely crowded. The patient’s companion requested that I check the patient's intravenous line. It took me a few moments to go and check the intravenous line, and because of the delay, the patient's companion used obscene language against me in front of others	Due to overcrowding, the nurse was delayed in providing care, and as a result, the patient's companion became enraged and used obscene language against her in the presence of others	The patient’s companion used obscene language against the nurse	Sexual insults	Verbal sexual harassment	Cases of sexual harassment in workplace
I was on the night shift, and in one of the rooms, there was a child with his father by his side. I had to take the child’s temperature on a regular basis because he had a fever. When I entered the room to take his temperature, the father grabbed me tightly and kissed my lips. I felt terrible	Abuse of the patient’s companion from a quiet ward, the nurse’s regular presence on the patient’s bedside, and kissing her by force and coercion	The patient’s companion kissed the nurse by force and coercion	Kissing	Physical sexual harassment
We were in the examination room when I noticed the doctor was looking at me oddly. I felt bad and were thankful that the patient was there, so he could not offend me; he looked at me as if I was naked. He was giving me the glad eye	A male doctor’s lustful stares and glances at a female nurse, instilling fear and violence in the nurse	The doctor’s lustful stares at the nurse	Lustful stares	Visual sexual harassment
Even though he was married and knew I was also married, one of the ward's male personnel claimed to have fallen in love with me. “I am willing to do anything for you; please do not ignore me,” he said. He was bothering me a lot; he brought me tea, said nice things to me, and wanted to have an affair with me	Even though he was married and knew I was married, one of the ward's male personnel claimed to have fallen in love with me. “I am willing to do anything for you,” he said, “please do not ignore me.” He was bothering me a lot, bringing me tea, saying sweet things to me, and wanting to have an affair with me	A male married colleague has fallen in unusual love to a married nurse	False expression of love and affection	Seduction
One of the doctors had my phone number. He would occasionally send me a message; to which I would politely respond. I do not know what he was thinking about me when he allowed himself to send love messages and sexual images on WhatsApp	Frequent messages to pave the way for sexual goals to be met by sending unconventional and sexual photos via social media	Male doctor sent unconventional sexy photos to nurse	Sending sexual images and videos	Cyber sexual harassment

Table 4

First, second, and main categories extracted from qualitative content analysis

Subcategories	Categories	Main category
- Dirty jokes - Request for informal contact - Unusual conversations about body and appearance - Talking about sex - Sexual insults	Verbal sexual harassment	Nurses sexual harassment in workplace
- Groping - Pushing - Cuddling - Kissing - Touching of the genitals - Removing the clothes - Rape	Physical sexual harassment
- Lustful stares - Exposing oneself sexual organs - Display of sexual symbols and acts	Visual sexual harassment
- False expression of love and affection - The tactic of marriage - Financial and professional support - Flattery - Disrespect for chastity	Seduction
- Unusual and Sexual phone calls and text messages - Sending sexual images and videos - Misuse of personal videos and photos	Cyber sexual harassment

Trustworthiness

Qualitative research typically uses four topics to describe different aspects of trustworthiness: credibility, confirmability, dependability, and transferability (Kyngas et al., 2020). Several strategies were applied in the current study to increase trustworthiness. By remaining in the field for a long time (1 year) to collect and evaluate data for the current study, the researcher aimed to build a good relationship with the participants. The researcher attempted to pick volunteers with various qualities in order to acquire more in-depth data (maximum variation). After reviewing each interview, we referred back to the participants and made adjustments as needed to clarify ambiguities and corroborate the extracted opinions (member check). In addition, two professional researchers were asked to examine and interpret the data, and all extracted codes and categories were verified and approved by the authors to ensure credibility. To improve data confirmability, the study team created and printed a mind map during the research process. Two members of the research team (qualitative research experts) were provided the transcripts of multiple interviews, as well as the codes and extracted categories, to double-check the data coding process accuracy. In order to establish dependability, the external observer strategy was used in this study to examine his likely comparable knowledge with the researcher and look for contradicting situations. As a result, the data was given to two researchers (both of whom were experts in qualitative research) who affirmed the data's reliability based on the same concept. To improve the data’s transferability and appropriateness, the research findings were given to two non-participant samples from the current study, and their comments were solicited, with a conceptual generalization based on the similarities. We have made an effort to detail all of the research steps.

Findings

The qualitative content analysis method was used in the study, which resulted in the explanation and definition of the meaning, dimensions, and components of the concept of “Nurses sexual harassment in the workplace.” After continuous comparative analysis and code condensation, 354 codes remained. Finally, the study’s findings were organized into a main category, five categories, and 23 subcategories (Table 4).

Main Category: Cases of Sexual Harassment in the Workplace

According to the participants’ experiences, there are five categories of cases of sexual harassment in the workplace: “verbal sexual harassment,” “physical sexual harassment,” “visual sexual harassment,” “seduction,” and “cybersexual harassment.”

Verbal Sexual Harassment

The participants’ experiences revealed that verbal harassment could take many forms. Dirty jokes, requests for informal contact, unusual conversations about the body and appearance, talking about sex, and sexual insults were among the forms of verbal harassment experienced by study participants.

Dirty Jokes

The majority of study participants reported that this type of harassment took the form of dirty jokes made by colleagues (doctors, nurses, hospital guards, service workers, and officials) as well as patients and their companions. Furthermore, the expression and interpretation of ordinary words to words with a sexual connotation is frequently the subject of colleagues’ jokes and laughter. In addition, both female and male colleagues have perpetrated these jokes, resulting in harassment.

“One day, the ward doctor told me a dirty joke that I did not fully comprehend, but I smiled because we were being told to treat well with doctors. At that time, I could not understand what the doctor was saying. I knew it was not an ordinary joke, but once I realized what it meant, my mind was occupied for a few hours, and I blamed myself for not being able to say anything.” (Participant No. 9, a female with four years of work experience).

Request for Informal Contact

Based on the experiences of some participants, some colleagues (doctor, nurse, ward secretary, and staff) and some patients and their companions offered an unusual friendship and an unconventional sex proposal regardless of the nurse’s desire in the hospital. They also insisted on having the nurse’s contact number or giving the nurse their contact information in some way. Both male and female participants had similar experiences. One of the participants also admitted that the harasser was attempting to legitimize his/her unusual proposal by bringing up the subject of “Sigheh” (temporary marriage in Iran).

“I was working the night shift in the emergency department. A woman arrived in the middle of the night, and I provided the care services and returned to the station. Suddenly, she started calling me. I went over to her bed and asked what was wrong; she took my hand in hers and asked me to stay by her side. She gave me her phone number and insisted on me writing it down. She requested to have an affair with me.” (Participant No.21, a male nurse with 6 years of work experience).

Unusual Conversations About Body and Appearance

According to the findings of qualitative data analysis, some female participants were harassed by a colleague, a doctor, as well as patients and their companions who admired their type, appearance, and body. Such harassment was in the form of annoying comments about the beauty of the arms and legs, the slim waist, eyes, brows, and facial beauty, or vice versa, about fat lower limbs, or about the type of clothing that nurses wear, particularly in private hospitals.

“One of the ward doctors once advised me to focus on my lower limbs because they did not match up with my upper limbs. He suggested that I go to the sports club. It is a discourteous conversation between a male doctor and a female nurse. I wonder how long he stared at my body before saying something like that.” (Participant No. 10, a 32-year-old nurse with ten years of work experience).

Talking About Sex

Some participants reported direct conversations between colleagues (physicians, nurses, guards, and service workers), patients, and their companions about the genitals, buttocks, breast, sex, and even menstruation and the type of underwear.

“There was a guard who spent a lot of time talking about sex. When I was alone at the station during the night shift with him, he would come up to me and talk about sex, which bothered me a lot. I tried not to listen to him.” (Participant No. 12, a 27-year-old woman with four years of clinical work experience).

Sexual Insults

Some participants claimed that patients and their companions verbally abused them using obscene language. In a few cases, doctors have used obscene language against nurses.

“We were on an emergency mission, and we were there in five to six minutes. As we wanted to enter the house, one of the residents began yelling obscenities at us because we were late. He said a lot of things that were extremely humiliating to us.” (Participant No. 20, a young man with 7 years of clinical work experience).

Physical Sexual Harassment

According to the findings of the qualitative data analysis, physical sexual harassment takes various forms, such as groping, pushing, cuddling, kissing, touching of the genitals, removing clothes, and rape.

Groping

The results of qualitative data analysis revealed that the patients, their companions, and colleagues, including the physician, nurse, workers, and guard, had harassed female participants on numerous occasions. Touching the buttocks and breasts, pinching, holding the nurse’s hand while caring, touching the foot, putting the hand on the shoulder, or the physician holding the nurse’s hand were all examples of this type of harassment. A female patient has also been observed taking the hand of a male nurse in this type of harassment.

“I was taking a young man’s blood pressure when he suddenly grabbed and touched my breast.” (Participant No. 2, a 50-year-old woman with 26 years of clinical work experience).

Pushing

Some participants were harassed by the patient's companion while providing patient care, such as taking blood pressure or venipuncture. In this type of harassment, the patients’ companions positioned themselves next to the nurse and pushed or jostled her in such a way that their intentional work became inadvertent. Furthermore, the nurses in the study had been subjected to this type of harassment during a doctor’s visit or in the operating room by a doctor and male colleagues, and they had been pushed under various pretexts, such as taking a photo and passing by the nurse.

“One of the hospital doctors always asked me to accompany him when he visited the patients in the ward. Then he deliberately pushed me and pretended that he was not intentional.” (Participant No. 1, a 25-year-old woman with 2-year work experience).

Cuddling

Female nurses were subjected to this type of harassment in the form of a surprise hug from the doctor, the patient, and his companion. Cuddling typically occurred in a secluded location such as a rest room, workroom, or the patient's private room, and it occurred more frequently during night shifts.

“I was working the night shift. I went into the workroom to get the medications ready for the patient. Suddenly, the ward doctor approached me from behind, wrapped his hands around my waist, and pressed me against his chest.” (Participant No. 5, a female nurse with a 24-year work experience).

Kissing

According to some female nurses’ experiences, some patients, either companions or colleagues (nurse and doctor), kissed the nurse by force and coercion in a private setting such as a private room or workroom.

“The patient caught and kissed me in the visiting room. I pushed the patient, but I couldn't get him to move.” (Participant No. 12, a nurse with 4-year-work experience).

Touching of the Genitals

A number of participants reported being harassed by the doctor, the patient, and his companion, who touched them from behind and made physical contact with their genital area.

“I was bending over taking blood from a child in the workroom when I felt the doctor touch me from behind, allowing me to feel his genital organ. I was taken aback.” (Participant No. 18, a 45-year-old woman with 15 years of clinical work experience).

Removing the Clothes

Two participants reported that the patient suddenly removed their scarf or clothes (this subcategory had three codes and was presented by two participants, both of whom experienced this type of harassment by the patients in the psychiatric ward, and despite the follow-up, this code was not repeated in subsequent interviews.)

“I was giving medicine to the patients when the patient in the next bed, a young man, removed my scarf. I was taken aback.” (Participant No. 16, a 42-year-old woman with 12 years of clinical work experience).

Rape

Three participants described being raped by a colleague and the patient’s companion. Despite follow-up, the codes in this subcategory were not repeated in subsequent interviews.

“A patient's companion harassed one of the married nurses. She told me that the patient's companion dragged her to the toilet and raped her.” (Participant No. 3, a 47-year-old woman with 23 years of clinical work experience).

Visual Sexual Harassment

Participants in the study were subjected to visual sexual harassment in the form of lustful stares, exposing oneself sexual organs, and the display of sexual symbols and acts.

Lustful Stares

According to the findings of qualitative data analysis, female participants were subjected to this type of harassment in the form of annoying and lustful stares from a colleague, patient, and his companion. According to some participants, the stares were so annoying that they made them feel awful.

“One day, while we were in the examination room with the doctor, I noticed that he was staring at me oddly. I felt bad, so I could not concentrate, and he was staring at me as if I was naked. He was giving me the glad eye.” (Participant No. 17, a 45-year-old woman with 19 years of work experience in a public hospital).

Exposing Oneself Sexual Organs

Female nurses in this study experienced this type of harassment in the form of exposing oneself sexual organs by a male patient. Male nurses were also harassed, so female patients purposefully opened their collars and exposed their breasts, necks, and hair to them.

“I had a male patient with a Shaldon femoral. I gave him a bedsheet to cover himself with and simply removed the head of the Shaldon catheter so that I could connect it to the device. When I entered the unit, however, I noticed that he had purposefully arranged the sheets so that his penis was clearly visible. I turned away and walked out.” (Participant No. 7, a 35-year-old woman with 16 years of clinical work experience).

Display of Sexual Symbols and Acts

Some participants experienced hand gesture with a sexual connotation by a male colleague and a patient, including pointing to sexual organs like buttocks, or raising the thumb.

“The ugly gesture she made in front of everyone showed her thumb. I did not expect a lady at all. Show a sex symbol.” (Participant No. 3, a 47-year-old woman with 23 years of work experience).

Seduction

The participants’ experiences reported seduction as one way of sexual harassment, which means that the abuser behaves in a way that attracts and abuses the victim, and finally, such behaviors lead to harm to the nurse. According to the participants’ experiences, the harassers achieve their goals through false expressions of love and affection, the tactic of marriage, financial and professional support, flattery, and disrespect for chastity.

False Expression of Love and Affection

This harassment takes the form of arousal of emotions through the use of romantic words and expressions, which is mostly perpetrated by married coworkers and doctors.

“One of the residents on the ward was always expressing his love for me. Despite the fact that he knew I was married, he wanted to have an affair with me.” (Participant No. 10, a 32-year-old woman with 10 years of work experience).

The Tactic of Marriage

This type of harassment was experienced by some participants in the study in the form of irrational marriage proposals from colleague and patients, as well as seduction and sexual abuse with false promises.

“One of the nurses had befriended one of the residents and had an affair with him. She told me that they were going to marry and that he had promised to marry her, but she later discovered that the resident had affairs with several other women.” (Participant No. 14, a 51-year-old woman with 28 years of work experience).

Financial and Professional Support

According to the experiences of some study participants, a nurse was forced to wear special clothing and makeup at work and to engage in an unconventional and sometimes sexual relationship in order to keep her job. The doctor also offered the nurse a job promotion with very reasonable pay.

“A doctor offered me a position. “I will pay you as much as you want,” he said. He owned a clinic and offered to pay for my taxi and give me a good wage. It was obvious why he was so nice to me. He was looking for a relationship with me.” (Participant No. 6, a 25-year-old nurse with 2 years of work experience).

Flattery

The participants experienced this type of harassment in the form of paying special attention to the nurse and performing female nurse care tasks without asking for help, being kind to the nurse, and being invited to the workroom by a male doctor and colleague.

“The ward head nurse, on the other hand, was a different story. Despite the fact that he was considered immoral, he was really kind to me. He agreed to allow me to modify my shift and request time off. On the other hand, he was married, and I had no negative feelings toward him” (Participant No. 13, a female with eight years of work experience).

Disrespect for Chastity

One of the participants experienced this type of harassment in the form of using negative words like “prudery” to provoke the nurse. Despite the fact that this subcategory was followed in subsequent interviews, no new code was added.

“One of my coworkers used to get very close to me while working or at the station, and his entire body would sometimes make contact with me. When I told him to go a little further, he called me a prude. I wondered if I was overly sensitive.” (Participant No. 2, a nurse with 26 years of work experience).

Cybersexual harassment

According to the findings of qualitative data analysis, this type of sexual harassment is in the form of unusual and sexual phone calls and text messages, sending sexual images and videos, and misusing personal videos and photos through electronic means and social networks.

Unusual and Sexual Phone Calls and Text Messages

Some participants reported this type of harassment in the form of numerous annoying phone calls and unusual romantic and sexually explicit text messages from a male colleague and physician.

“A male colleague was texting me on WhatsApp. I responded to his messages, which were normal, but after a while, he sent me a sexy message.” (Participant No. 15, a 43-year-old woman with 19 years of clinical work experience).

Sending Sexual Images and Videos

Some study participants reported that a doctor and a patient had sent sexy and pornographic images, videos, and stickers via social media platforms such as WhatsApp.

“I was working with a male colleague on the night shift. He spent the entire night on his cell phone, and when I asked what he was doing, he showed me his cell phone without hesitation. I noticed he was watching a pornographic movie. I became embarrassed and quickly turned away.” (Participant No. 4, a 48-year-old woman with 26 years of clinical work experience in a public hospital).

Misuse of Personal Videos and Photos

According to the experiences of three participants, this type of harassment posed a threat to the publication of personal photos and the secret filming of nurses by a male patient. Despite the fact that this subcategory was followed in subsequent interviews, no new code was added.

“After discharge, the patient called and threatened to share my photos with others. He claimed to have hacked into my phone and accessed private photos. The specifications he gave me were correct.” (Participant No. 8, a 25-year-old nurse with 4 years of work experience).

Discussion

The goal of this study was to look into the experiences of Iranian nurses who had been sexually harassed. According to the participants’ experiences, sexual harassment in the nursing workplace is a common occurrence that occurs in a variety of situations. According to the findings of this study, nurses have been subjected to various forms of sexual harassment. In the nursing workplace, there are different types of sexual harassment, including verbal, physical, visual, and cyber sexual harassments, as well as seduction. These findings are consistent with the findings of other studies (Budden et al., 2017; Ghona & Ezz El Rigal, 2019; Nielsen et al., 2017; Suhaila & Rampal, 2012). Behboodi-Moghadam et al. conducted a qualitative study on Iranian women’s workplace harassment experiences and discovered that sexual harassment was uncommon. Perhaps the difference in results is because this study examined psychological harassment, physical harassment, and sexual harassment but did not focus on sexual harassment. On the other hand, this research was carried out in a variety of work environments, all of which differed from the nursing workplace (Behboodi-Moghadam et al., 2018).

In this study, nurses experienced verbal sexual harassment more frequently and in a variety of forms. Maghraby et al. investigated sexual harassment in the workplace among nurses at an Egyptian hospital and discovered that verbal sexual harassment was the most common, accounting for 53.5% of all cases (Maghraby et al., 2020). Anwar et al. studied three types of sexual harassment of women in public places in Pakistan and found that nonverbal sexual harassment, such as staring, giving unreasonable gifts, blocking the path, and undressing, was the most common, followed by physical and verbal sexual harassment. The difference is probably because this study was carried out in public places other than the workplace. There are also limited social interactions between men and women in Pakistan because of cultural differences. Physical contact and sexually explicit statements with women are not publically acceptable and perpetrators can choose to use non-verbal forms (Anwar et al., 2019). In the present study, a large number of nurses in the workplace were subjected to dirty jokes, sexual insults, direct remarks about sexual issues, admiration of body and appearance, informal contact, talking about private matters, or being under pressure to disclose their contact number. These findings are consistent with those of previous studies on nurses, nursing students, and other health professionals (Chang & Cho, 2016; Maghraby et al., 2020; Mamaru et al., 2015; Zeng et al., 2019). Verbal harassment is one of the most common kinds of sexual harassment where the abuser often speaks erotic words for sexual pleasure (Shokri & Hashemi, 2014). For many Iranian men, verbal harassment is still a sign of superiority and uniqueness (Riahi & Lotfi Khachaki, 2016).

According to the findings of this study, a number of nurses were physically abused, and physical sexual harassment was the second most common form of harassment after verbal sexual harassment. These findings are consistent with those of other studies (Tollstern Landin et al., 2020; Zeng et al., 2019). Physical sexual harassment manifests itself in a variety of ways. Other studies have reported physical harassment such as kissing, cuddling, touching the nurse's hand, touching the nurse's body without her consent, pushing, pinching, and caressing (Anwar et al., 2019; Schoenefeld et al., 2021). Furthermore, nurses were rarely raped or sexually assaulted. These findings are consistent with those of other studies (Abo Ali et al., 2015; Subedi et al., 2013). Iran, as an Islamic society with a distinct cultural context, has traditional laws that individuals, particularly women, are required to follow (Lahsaeizadeh & Yousefinejad, 2012). Any physical contact between a non-mahram (a non-Mahram is a person with whom marriage is generally permissible) man and woman is forbidden under Islamic law and is considered sexual harassment. Despite the fact that sexual harassment is a global phenomenon and has been raised as a serious issue in most societies around the world, it is still regarded as taboo in Iranian society. Discussing sexual issues is frowned upon, and it is believed that problems involving sexual harassment should be kept private. The negative social attitude towards victims causes them to remain silent for fear of being accused and stigmatized (Shokri & Hashemi, 2014). Therefore, harassers have taken advantage of the circumstance to physically abuse nurses in private rooms or in quiet areas.

The results of the present study revealed that some nurses were subjected to visual sexual harassment. Lustful stares, exposing oneself sexual organs, and the abuser touching and stimulating the genital area are all examples of visual sexual harassment. This type of harassment has occurred in other studies (Abo Ali et al., 2015; Hussein et al., 2015; Subedi et al., 2013). Kim et al. investigated the experiences of 191 Korean senior nursing students with sexual harassment. In this study, 40.2% of students were harassed by lustful stares, 8.2% were harassed by harassers intentionally touching or showing their own genitals, and 5.2% were harassed by harassers showing sexual acts associated with sexual intercourse (Kim et al., 2017). Some behaviors, such as looking at the hair and body of a non-mahram, which often leads to sexual excitement, are prohibited in Iran due to the prevailing customs of society and the religion of Islam, as well as the special culture that controls the relationship between men and women, and proper dressing is emphasized to prevent this harassment. According to previous research, many women believe that the type of clothing they wear at work is important in preventing sexual harassment (Behboodi-Moghadam et al., 2018).

Seduction was one of the types of sexual harassment mentioned by study participants. False expressions of love and affection, marriage tactics, financial and professional support, flattery, and disrespect of chastity were the most common forms of sexual harassment. In addition to courtship and insistence on marriage (Scholcoff et al., 2020), unwanted sexual attention, and seductive behaviors were observed in other studies (Kahsay et al., 2020). In Iran's cultural-religious context, any sexual intercourse other than marriage is forbidden, and sexual intercourse is only permitted in the form of marriage (Mirshekari & Samadi, 2020). As a result, some harassers deceive the victim by promising marriage in exchange for a sexual relationship with her. This is against both custom (norms of society) and Sharia (Islamic religion) law. Furthermore, harassers who are aware of nurses’ financial difficulties may deceive them with a promise of high wages or demand a sexual relationship in exchange for the work assigned to them.

Another type of harassment, according to research, is cyber sexual harassment. Some of the nurses in the current study were subjected to this type of harassment in the form of unusual and sexual phone calls and messages, the receipt of pornographic photos and videos via social media, and the misuse of personal videos and photos. Thapalia et al. investigated the sexual harassment experiences of female students in Nepal and discovered that 15.4% of students were harassed via mobile phones and 11.3% received nude and pornographic photos or dirty jokes via Facebook and email (Thapalia et al., 2019). Furthermore, according to the findings of a study on female university students in Egypt, 79.8% of the students were sexually harassed at least six times in cyberspace (Arafa et al., 2017). The advancement of information technology, the increased use of the Internet, and the advancement of social relations through computer-based processes have increased the use of social networks to the point where they are now an integral part of people's lives. The COVID-19 spread has had a major impact on social media usage. Although membership in various social networks and virtual communication with others has provided a valuable opportunity to share knowledge and professional and personal records, improper use of these networks can result in irreversible harm, such as privacy breaches and the phenomenon of sexual victimization. This crime can take many forms, including sexual harassment, extortion, and sending pornographic images, videos, and texts, as well as pornography (Danesh Nari et al., 2018). As this type of harassment has emerged with the advancement of science and technology and has been reported in some similar studies (Hussein et al., 2015; Subedi et al., 2013), appropriate control strategies are required. Given the prevalence of both traditional and cyber sexual harassment, preventive strategies that address both types of harassment can be beneficial.

Sexual harassment is essentially subjective and is defined by the social, economic, and cultural contexts (gender stereotypes, hierarchies, norms, etc.) in which it occurs, as well as the various types of offensive behaviors that are considered different in different cultures (McCann, 2005). Nielsen et al. (2017) demonstrated that sexual harassment is a multifaceted and complex phenomenon. In practice, however, sexual harassment frequently causes a wide range of problems in the workplace. Workplaces rarely have guidelines or policies in place to manage and/or prevent sexual harassment or inappropriate sexual behavior, and this is frequently addressed on a temporary and sporadic basis (Nielsen et al., 2017). Therefore, a training program for sexual harassment prevention in nursing, as well as a systematic reporting system are required. There are effective strategies to deal with nurse harassment, such as documenting each incident and initiating legal proceedings, condemning sexual abuse, demanding severe punishment for perpetrators, and improving the image of nurses in the media. Healthcare facilities should adopt policies and strategies aimed at reducing harassment and creating a safe working environment for nurses (Zeighami et al., 2021).

Limitations

The participants’ fear of disclosing the information they provided to the researcher was a limitation of this qualitative study. Given the Iranian cultural context and the nature of the phenomenon under study, which is considered taboo and difficult to discuss for a variety of reasons, including religious norms, participants refused to explain details and sometimes their own experiences. To address this limitation, the researcher first described to the participants the research objectives and how such research can help minimize the problem by boosting public awareness and being helpful in establishing rules. As a result, the researcher told the participants that all of their information would be kept private and attempted to collect the needed information by developing trust and attracting their attention. Another limitation was the low number of male participants compared to female participants. In terms of gender discrimination, the majority of nurses were female, with a minor number of male nurses. According to research, the power imbalance between the perpetrators of sexual harassment and women, society's patriarchal attitude, attention to women as a sexual means, lack of supervision in some areas of work, such as the private sector, and misconceptions about nurses and women, as well as blaming them, are among the main reasons why women are the majority of victims of sexual harassment in the workplace. The researchers also attempted to interview as many male participants who had experienced sexual harassment as possible, although the low number of participants was beyond their control.

Conclusion

When the experiences of nurses with sexual harassment were examined, it was discovered that sexual harassment takes many forms, including verbal, physical, visual, and cyber sexual harassment and seduction. Patients, their families, doctors, coworkers, and other service personnel are all examples of harassers. Given the negative consequences of these types of harassment, it appears that additional quantitative and qualitative research on sexual harassment, policies and strategies to prevent and eliminate sexual harassment in medical settings and other health groups are required to confirm the findings.