|ORIGINAL RESEARCH ARTICLE
|Year : 2021 | Volume
| Issue : 2 | Page : 55-63
Self-perception of sexual harassment: A comparison between female medical and nursing students during clinical practice
Fatehpal Singh A/L Waryam Singh Malhi1, Sandheep Sugathan2, Nik Ameera Syafiqa Binti Azhar3, Wan Imanah Nabilah Binti Wan Roslan3, Hanan Asrawi Binti Abu Bakar3, Siti Maisarah Binti Zolkaine3
1 Associate Professor, Department of Obstetrics & Gynaecology, Universiti Kuala Lumpur Royal College of Medicine Perak, Ipoh, Malaysia
2 Professor, Department of Community Medicine, Quest International University, Perak, Malaysia
3 Medical Officer, Ministry of Health, Malaysia
|Date of Submission||08-Oct-2021|
|Date of Acceptance||28-Oct-2021|
|Date of Web Publication||21-Dec-2021|
Fatehpal Singh A/L Waryam Singh Malhi
Universiti Kuala Lumpur Royal College of Medicine Perak, Ipoh
Source of Support: None, Conflict of Interest: None
Background: Sexual harassment (SH) may occur anywhere in the world, including the hospital setting. Medical and nursing students are not excluded from being sexually harassed during their clinical practice. This study examined the experiences and compared the perception of SH between female medical and nursing students during their clinical practice in Perak, Malaysia. Methods: A comparative cross-sectional study design was done among female medical and nursing students during their clinical practice. Results: Total respondents were 481 female medical and nursing students (response rate of 96.2%). About 17.8% of medical and 18.8% of nursing students had been sexually harassed. The most common harasser for medical and nursing students were males (51.2% and 48.8%, respectively), patients (39.7% and 60.3%, respectively), age 30s (41.0% and 59.0%, respectively) and 40s (65.5% and 34.5%, respectively), occurred in medical wards for both groups (50% each). From the SH checklist, 76.9% of medical and 73.5% of nursing students had experienced at least one item of the total 18 items. The abnormal sexual desire of an individual was chosen as the reason for SH by 44.9% of medical and 33.8% of nursing students. The majority of respondents said the issue of SH in clinical practice was very serious. Around 32% of medical students choose the fear of being disadvantaged during clinical practice as the reason why the victims kept quiet while 41.5% of nursing students chose because of not having evidence. Both groups of students suggested establishing rules and laws relating to SH (30.8% and 35.5%, respectively) as effective methods to prevent it. About 75.3% of medical and 81.6% of nursing students agreed that it was very necessary for implementing a SH prevention program. Discussion: Although SH is not a new issue, there is insufficient exposure about SH among medical and nursing students. This can be corrected by increasing their knowledge and awareness about SH.
Keywords: Female, Malaysia, medical students, nursing students, perception, sexual harassment
|How to cite this article:|
Waryam Singh Malhi FS, Sugathan S, Binti Azhar NA, Binti Wan Roslan WI, Abu Bakar HA, Binti Zolkaine SM. Self-perception of sexual harassment: A comparison between female medical and nursing students during clinical practice. Educ Health 2021;34:55-63
|How to cite this URL:|
Waryam Singh Malhi FS, Sugathan S, Binti Azhar NA, Binti Wan Roslan WI, Abu Bakar HA, Binti Zolkaine SM. Self-perception of sexual harassment: A comparison between female medical and nursing students during clinical practice. Educ Health [serial online] 2021 [cited 2022 Jan 27];34:55-63. Available from: https://www.educationforhealth.net/text.asp?2021/34/2/55/332958
| Background|| |
Sexual harassment (SH) is defined by United Nations as unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature. This causes an individual to feel threatened, humiliated, or embarrassed. SH is one of the most common problems affecting women all over the world and the topic has become part of heated arguments and discussions among the general public, including in Malaysia. According to a study, approximately one in two women will be harassed at some point throughout their academic or working lives.
In Malaysia, local studies show that the frequency of SH ranges between 35% and 87%., Media outlets have been covering reports about women who experience SH at work. However, many go uncovered and unreported due to the victims' unwillingness to confess and report to their administration because of the ensuing discrimination[ 5] which may cost them their jobs.
Health-care settings are not excluded from SH. There were substantial reports of cases occurring in the clinical environment. Female nurses are the most vulnerable for SH among the hospital staff. The prevalence of SH in nursing is alarming at 60% and 34% for female and male nurses respectively.
Although the percentage of women who had observed and heard about SH was approximately the same as men, women who had experienced SH were twice that of men.,, Men are also subjected to SH, but they experience different forms of SH among their colleagues as compared to women.,
According to nurses, the main perpetrators were patients and physicians. A study conducted in two general hospitals in Taiwan showed that female nurses were sexually harassed mainly by the patients, followed by co-workers and the patients' family members.
Another study carried out in four hospitals in Kolkata, India; showed that female doctors were frequently harassed by their male colleagues, whereas nurses were harassed by patients and their families.
There are broad differences in an individual's recognition and perception toward SH, which is influenced by one's gender, culture, religion, and knowledge regarding SH. In a study done among female nursing students in South Korea, the result showed that 17.9% had been sexually harassed during their clinical practice, 75.5% never encountered SH and the rest did not know whether they had experienced SH or not. There was considerable inconsistency between the reported experience rate (17.9%) and the checked items in the SH checklist. On analysis, 52.0% of respondents have experienced at least one of the items in the checklist. This discrepancy may be due to insufficient knowledge and awareness regarding SH.
We believe it is important to recognize the frequency of SH experienced during clinical practice; the perpetrators, form of behaviors perceived as SH, and the perception and response to SH among the female medical and nursing students. It is hoped that this study may not only empower medical and nursing students regarding SH but also increase public awareness of its devastating effects on the psychological health of the victims and the organization's productivity.
This research was conducted to determine the experiences and self-perceptions of SH and to compare if there were any significant differences in experiences and perceptions of SH between female medical and female nursing students during their clinical practice in Perak, Malaysia.
| Methods|| |
This is a comparative cross-sectional study using self-administered questionnaires.
Sample and setting
A convenience sample of 500 female medical and nursing students was collected from Universiti Kuala Lumpur Royal College of Medicine Perak (UNIKL RCMP), Quest International University Perak (QIUP), and Ministry of Health Sultan Azlan Shah Training Centre (MOH SASTC) in Malaysia (assuming that 50% of female medical and nursing students were sexually harassed with a precision of 5% for a 95% confidence level.). The total number of female medical and nursing students from these selected institutions was 1200. The inclusion criteria were being Malaysian citizens, age 20 and above, female, medical and nursing students from UNIKL RCMP, QIUP, and MOH SASTC who had entered clinical settings in the General Hospital, District Hospital A, District Hospital B, and District Hospital C, and were willing to participate in the research and sign the consent form. Non-Malaysian students, those who had not entered clinical settings and who were not willing to participate in this research were excluded. From a total of 500 female medical and nursing students who were invited, 481 voluntarily agreed to participate in this study (response rate of 96.2%) [Table 1].
|Table 1: Demographic data of respondents from different institutions in Perak, Malaysia|
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This study used a validated questionnaire adapted from a study done by Lee et al. to measure respondent's perception on SH. However, this questionnaire was reviewed, edited, and improvised to suit our local setting. Ten medical students and ten nursing students were invited to partake in the pilot testing. The questionnaire was set in English and the national language i.e., Bahasa Melayu for easier understanding.
Respondents filled up their socio-demographic details, i.e., age, ethnicity, place of study, field of study, semester, the hospital attached to and the duration of their clinical attachment.
Experience of sexual harassment
The experience of SH was measured by a two-step procedure. First, the participants were asked whether they had experienced SH during their clinical practice before. There were three options, “Yes,” “No,” and “I don't know.” If the respondent answered “Yes,” seven additional questions were asked on the frequency of SH, time of day when SH occurred, characteristics of the harasser (sex, occupation, and age), and characteristics of the clinical setting (place and location). The respondents were then asked about SH experienced in their clinical settings. The second part of the questionnaire contained 18 items that had six questions on verbal SH, four questions on physical SH, five questions on visual SH, and three questions on gender-related demands.
Perception of SH The questionnaire contained five categories, i.e., causes of SH, the seriousness of SH during clinical practice, reasons for not making SH an issue, effective methods in preventing SH, and the necessity for an SH prevention program.
Procedure and ethical consideration
This study was approved by the Ethics Committee of UNIKL RCMP and Medical Research and Ethics Committee of the National Medical Research Centre, Ministry of Health Malaysia. Permissions for data collection were obtained from the three colleges where the research was conducted. Hard copies of the questionnaires were then given to the batch representatives. Data were collected by a self-administered questionnaire in the classroom using break times between classes in each college and returned to the research team by hand from December 2017 to April 2018.
After giving information about the purpose of this study, guarantees for anonymity and credibility, voluntary participation, and expected time to complete a questionnaire (9–15 min), written informed consent was obtained from all participants who volunteered for this study. Questionnaires were then distributed and collected on the spot immediately after completion.
Data entry was done through Microsoft Excel and analyzed using IBM SPSS program version 20 trial version (Statistical Package for Social Sciences developed by International Business Machines Corporation, New York) trial version using descriptive statistical methods and appropriate inferential statistical measures such as Chi-square test.
| Results|| |
General characteristics of the study participants
All the medical students from RCMP and QIUP were from Years 3, 4, and 5, while all the nursing students from RCMP and MOH SASTC were from Semesters 1–6. They were chosen this way based on their clinical exposure.
Demographic data of respondents from different institutions in Ipoh are presented in [Table 1].
Distribution of study participants based on frequency of SH experience is described under [Appendix 1].
About 68.8%, 47.2%, 34.5% and 17.3% of participants had at least one experience of verbal SH, physical SH, visual SH and gender related demands respectively. Overall 75.3% of participants experienced at least one form of SH.
The differences in SH experience during clinical practice between medical and nursing students is described in [Table 2].
There was no significant difference (P > 0.05) in the overall experience of SH between the medical and nursing groups. However, there was a significantly higher proportion of medical students who were more frequently sexually harassed (more than 6 times) than nursing students (P < 0.05). Surprisingly, medical students were harassed by medical doctors and their own colleagues (P < 0.05). A significantly higher proportion of medical students were harassed in psychiatric wards and intensive care units (P = 0.004).
Difference in proportion in SH experience between medical and nursing students are described in [Table 3].
|Table 3: Difference in proportion of sexual harassment experience between medical and nursing students|
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A significantly higher proportion of medical students experienced verbal SH by being called with terms of endearment, hearing sexual comments on appearance, and receiving dirty talk from harassers (P < 0.05). Among the nursing students, a significantly higher proportion experienced verbal SH by the use of violent/abusive language (P < 0.05). In the category of physical SH, a significantly higher proportion of nursing students experienced forced sexual acts as compared to medical students (P < 0.05). A higher proportion of nursing students also experienced seeing the harasser touching or exposing their genitalia as compared to medical students (P < 0.05). In the gender-related demands category, a significantly higher proportion of medical students were forced by the harasser to break personal boundaries as compared to nursing students (P < 0.05).
Physical SH, “having stared at on a particular body part such as breasts or hips,” had the highest percentage from both medical (37.2%) and nursing students (38.5%). For visual SH, 19% of medical students “have received pornographic letters, photos, or videos through Internet” while 30.8% of nursing students “have seen harasser touching their genitalia.” For gender-related demands, 13.4% of medical students were forced to break personal boundaries while 9.4% of nursing students were asked to go to unwanted meetings or have relations with the harassers.
Perception of students on SH during clinical practice are described in [Table 4].
|Table 4: Perception of students on sexual harassment during clinical practice|
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A significantly higher proportion of medical students chose abnormal sexual desire of an individual and perception of considering women as sexual objects as the causes of SH (P < 0.05), while a significantly higher proportion of nursing students chose men's sexual impulse or instinct and being stimulated by women's physical exposure as the causes of SH (P < 0.05). A significantly higher proportion of medical students chose fear of being disadvantaged during clinical practice (P < 0.05) as a reason for not making harassment an issue. However, a significantly higher proportion of nursing students chose not to make SH an issue because of lack of evidence (P < 0.05).
| Discussion|| |
This study on the self-perception of SH between female medical and nursing students during clinical practice was done based on a study in Korea about SH experienced by nursing students. This allowed analysis of the rate of SH experienced during the clinical practice of medical and nursing students in Perak, Malaysia, and also to give basic information for a better environment during clinical practice.
In this study [Table 2], 17.8% of medical and 18.8% of nursing students answered they experienced SH during their clinical practice. However, when they were given a list of 18 items with various forms of SH [Table 3], 76.9% of medical and 73.5% of nursing students reported to experience it at least once during their clinical practice. This was a big difference between those who admitted that they were sexually harassed and those who ticked at least experienced one item among the 18 items of SH. This may be due to a lack of knowledge regarding SH. In the study done by Lee et al., Korean nursing students did not know the exact meaning or actions considered as SH because of low gender sensitivity. This supports the available local studies that mentioned the frequency of SH in Malaysia as ranging between 35% and 87%.,
In comparison to the study in Korea, 17.9% of the nursing students had experienced SH while 52.0% checked on the 18 items checklist. This agrees with the results obtained above. More students unknowingly experienced SH compared to those that had knowingly experienced SH. Results obtained from our study were higher compared to the 35% obtained in a British study, 52% in a South Korean study, and 53.3% in a Turkish study. This may be so because in Malaysia, there is the idea of male dominance over women, occupational characteristics of nursing which are mostly women, frequent physical contact in various environments, and nursing care through a sense of closeness and emotional communion. Bronner et al.(2003) showed that nursing students held the lowest position in the hierarchy during clinical training which is probably why they were more vulnerable to SH.
The most common characteristics of a harasser for medical students [Table 2] were males (17.8%), patients (9.3%), in their 40s (7.7%), frequently occurred in medical units (11.7%) and in the General Hospital (7.3%). As for nursing students, harassers were described as males (17.9%), patients (15.1%), in their 30s (9.8%) and usually happened in medical units (12.4%), and in the General Hospital (17.1%). Most cases were reported in the General Hospital as there are many medical wards in the hospital and almost all medical and nursing students had been posted there. Our study found that most cases happened in medical wards, whereas in Korea, most happened in the psychiatric ward.
Patients (9.3%), medical doctors (4%), and colleagues (4%) were common harassers for medical students [Table 2]. Medical students spent most of their time together with patients, doctors, and colleagues during clinical practice. Alternatively, nursing students were frequently harassed by patients (15%) and caregivers/patient's relatives (5.6%) because patient care requires spending more time with patients and caregivers. This is supported by a South Korean study where 96.9% of nursing students were sexually harassed by patients. As stated in the study, most hospitals emphasize the satisfaction and rights of patients and if patients complained or refused nursing care, the students may be denied the opportunities to practice. The same applies to medical students.
Most of the students had at least experienced verbal SH once, followed by physical SH, visual SH, and gender-related demands [Table 3]. This result coincides with previous studies reporting that verbal SH has the highest incidence.,,, About 56.7% of medical students had been called using terms of endearment while 35.9% of nursing students frequently heard violent/abusive language used against them. This was different from the study in Korea that stated having heard a comment of sexual evaluation of an appearance as the most received verbal SH. This shows that even though the same SH occurred, the sensitivity and awareness of SH are different depending on jobs, genders, prior experiences of SH, and social position.
Perception of sexual harassment during clinical practice
Around 35.2% of medical students and 39.3% of nursing students agreed that SH in clinical practice was very serious [Table 4]. This showed that most of the participants knew there were SH cases happening in their surroundings, but it was not raised as an issue. 44.9% and 33.8% of medical and nursing students chose abnormal sexual desire of an individual as the cause of SH, while 26.1% of nursing students chose men's sexual impulse or instinct as causes of SH. This finding was supported by the previous study in Korea which stated that 34.5% of the nursing students think that abnormal sexual desire of an individual was the main cause of SH followed by men's sexual impulse or instinct (26.2%). This proved that most respondents had similar perceptions regarding SH. Most students considered it as unalterable characteristic of men and agreed that it was gender related and not due to patriarchal hierarchy which stated males have a higher standing than females.
About 32% of medical students and 17.5% of nursing students chose “afraid of being disadvantaged during clinical practice” as reasons for not making SH an issue. Further, 41.5% of nursing students chose “not having evidence” as the main reason compared to only 18.6% of medical students. This finding suggested that respondents wanted to report the cases but were worried that it would backfire and affect their clinical training. Hence, most of the cases were buried without any closure or help offered to the victims. Victims may end up having a high level of psychological distress and physical problems.
The majority of medical and nursing students answered that it was very necessary to have SH prevention programs; 75.3% and 81.6%, respectively. Most of them saw SH as a big problem which needed more exposure to the public. 30.8% of medical and 35.5% of nursing students chose to establish rules and laws relating to SH as the most effective way to prevent SH. 30.3% of nursing students called for enforcement of a heavy penalty to the harasser, while 28.7% of medical students chose developing a healthy working environment (organizational culture). This implores that the related authorities need to take action on this issue of SH for the benefit of vulnerable individuals in our society.
Although the odds ratio may give better analysis, as this is a cross-sectional study using a structured questionnaire, we are unable to apply multivariate analysis to calculate the odds ratio.
| Conclusion|| |
The experience and perception of SH among female medical and nursing students during clinical practice are significant. SH is toxic for human development, hence authorities need to draft and enforce laws related to SH. There is a need for continuous education about SH to increase knowledge and awareness regarding this matter and also among the population. This will enable victims to tackle it without fear of repercussion.
Financial support and sponsorship
No financial support obtained for this research.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]