Health Letter, February 2019
By Azza AbuDagga, M.H.A., Ph.D.
Sexual contact between health care professionals and their patients is a serious ethical and public health problem that causes considerable and enduring harm to patient victims, damaging their self‐esteem and emotional well‐being and shattering their trust in health care professionals.
Yet the scope of this problem has not been investigated adequately, particularly in nursing, a profession in which the risk of sexual misconduct is high because nurses often spend long hours with their patients and the care that they provide often involves close proximity to patients. This prolonged closeness may make it more difficult for nurses than for other health care professionals to maintain clear roles and boundaries.
On Dec. 17, 2018, Public Citizen’s Health Research Group published a research study in Public Health Nursing that showed that U.S. nurses have rarely been reported to the National Practitioner Data Bank (NPDB) for sexual misconduct.
Our study analyzed anonymized NPDB data pertaining to nurses from Jan. 1, 2003, through June 30, 2016. Run by the Department of Health and Human Services, the NPDB is the only national repository of reports about health care professionals, including nurses, who have been subject to adverse state licensing actions (or adverse actions taken by other entities, such as hospitals) or had malpractice payments. This information is required to be reported to the NPDB in accordance with the Health Care Quality Improvement Act of 1986.
Specifically, we examined two types of NPDB reports for nurses during our study period: disciplinary licensing actions taken by state nursing boards (licensure) and malpractice-payment reports.
Only 882 U.S. registered nurses (RNs), advanced practice nurses (including nurse anesthetists and nurse practitioners) and licensed practical nurses (LPNs) or licensed vocational nurses (LVNs) had at least one sexual-misconduct–related licensure or malpractice-payment report related to sexual misconduct during the study period. Notably, the total number of these types of nurses in the U.S. (general U.S. nurse population) was 3.4 million in 2010, the median year of our study period, according to estimates from the Bureau of Labor Statistics.
Sixty-three percent of the nurses with sexual-misconduct–related reports identified in our study were aged 35 to 54, whereas only 52 percent of the general U.S. nurse population was in this age group in 2010. Although men are a minority in the nursing workforce (less than 10 percent of RNs are men, for example), 63 percent of the nurses with sexual-misconduct–related NPDB reports were men. LPNs and LVNs accounted for 39 percent of the sexual‐misconduct–related reports for nurses, although these nurse types make up only 17 percent of the general U.S. nurse population.
The majority (866) of the nurses with sexual-misconduct–related reports were reported by state nursing boards. Nursing boards administered harsh punishments in most of these cases: 91 percent of such reports involved serious actions — including revocation, suspension or voluntary surrender of the nursing license. In contrast, state nursing boards took serious actions in only 75 percent of cases related to other types of offenses.
Information about the victims in nurse sexual-misconduct–related reports was available only for incidents that led to malpractice-payment reports. These reports showed that 75 percent of these victims were female and 36 percent of them were aged 20 to 39. In contrast, 54 percent of the victims in other incidents leading to nurse malpractice-payment reports were female and 21 percent of them were aged 20 to 39. “Emotional injury only” was reported as the severity of malpractice injury for victims in 92 percent of the nurse malpractice-payment reports due to sexual misconduct, compared with just 2 percent of the malpractice-payment reports due to other nurse offenses.
Slightly more than one-half of the nurse sexual-misconduct incidents that led to malpractice-payment reports occurred in outpatient settings. In contrast, only about one‐third of the malpractice-payment reports related to other nurse offenses occurred in outpatient settings.
An important finding of our study is that of the 33 nurses who were reported to the NPDB for sexual misconduct that led to malpractice-payment reports, 16 (49 percent) had no sexual-misconduct–related licensure reports, indicating that these nurses were not disciplined by any state board of nursing for this misconduct. This finding is consistent with that of our 2016 study: 70 percent of U.S. physicians (177 out of 253) who engaged in sexual misconduct that led to malpractice-payment reports or to clinical-privileges (sanctions by hospitals or other health care organizations) reports were not disciplined by state medical boards for their unethical behavior.
Our new study showed that over nearly 14 years, only a small fraction (0.6 percent) of nurses with NPDB reports that met our study criteria were reported because of sexual misconduct. This finding is similar to that from our 2016 study that showed that approximately 1 percent of NPDB physician reports over nearly an 11-year period were due to sexual misconduct. It also is consistent with the finding of the National Council of State Boards of Nursing that just 0.5 percent of the nurses who were disciplined by state boards of nursing from 1996 to 2006 had committed sexual misconduct or abuse violations with their patients.
Although the actual prevalence of nurse sexual misconduct in the U.S. is unknown, we believe that our study captures only the “tip of the iceberg” of the problem. In fact, an anonymous survey of psychiatric nurses found that 11 percent of female nurses and 17 percent of male nurses reported having had sexual contact with their patients. Similarly, anonymous surveys of physicians indicate that 3 percent to 10 percent of the respondents reported engaging in sexual relationships with their patients.
Certain factors can explain the disparity between our findings and information from previous surveys. Many sexual violations against patients go unreported because these victims are often reluctant to complain due to feelings of guilt and shame, and fear that they will not be believed. Importantly, abused patients and their families may not know that they can complain to a state board of nursing or how to do so even if they know it can be done. Furthermore, complaining to state boards of nursing and participating in the investigation and legal proceedings of these cases can be very stressful to patient victims.
Although 38 percent to 52 percent of health care professionals report knowing of colleagues who have been sexually involved with patients, there is a “conspiracy of silence” about this problem because health care professionals tend to be reluctant to report their colleagues.
Additionally, the finding that nearly half of the nurses with sexual‐misconduct related malpractice‐payment reports had no adverse licensure actions for this behavior demonstrates inaction on the part of state nursing boards. This is because malpractice insurers are required to send copies of the reports they submit to the NPDB to nursing boards in their respective states, and nursing boards can query the NPDB to obtain access to all malpractice‐payment reports for nurses who have these reports.
We call on the health care community and the legal system to take sexual misconduct by health care professionals, including nurses, more seriously and to discipline those who are found to have exploited their patients sexually.
Such unethical behavior in health care should be designated as “never events”: No patient should ever experience any form of sexual misconduct, or fear of being subjected to such behavior, by any type of health care professional.
Therefore, we would welcome a zero‐tolerance standard against the most egregious forms of sexual misconduct: those involving physical sexual contact with patients.
Although educating health care professionals is an important part of the solution to this problem, certain unethical professionals may not be deterred. Therefore, it is incumbent upon the health care community and regulators, especially professional licensing boards, to rid the health care system of this public health problem.