Since arriving at the skilled nursing facility after surgery for throat cancer, Ray had been attempting to touch female nurses inappropriately and had recently started making kissing motions at one of them whenever she entered and left the room.

Tacit acceptance of the unacceptable.

Though his behavior was recognized as unacceptable, most nurses had simply been redirecting him or telling him to stop, with no further consequences. Some explained the harassment away as the crude behavior of an old man who didn’t know any better. He’s from a different time; things were different back then. Some dismissed it as harmless. He thinks he’s being flirty. For others, his behavior was a mild though not particularly threatening irritation. He can’t even get out of his wheelchair—what’s there to worry about?

A symptom of cognitive decline, or plain old bullying?

The situation was complicated by the fact that Ray could not communicate verbally as a result of surgery, had short-term memory impairment, and difficulty concentrating. Although he appeared cognitively sound, there were just enough complications in communication and attention to cause some to speculate that he might be having neurocognitive decline that had disinhibited his self-restraint.

For others, Ray was a bully, maybe even a predator. He was taking advantage of access to female staff who were required to be in his close proximity, as well the pressure of high caseloads and institutional demands to be ‘productive.’ As one nurse put it, “I’ve got to pass meds for 30 patients before doing wound dressings. I don’t have time to deal with his nonsense today, and neither does my director.” Addressing his behavior would take time and energy.

Disagreement among staff about how to respond.

Moreover, the situation had created disagreement among nursing staff. Those inclined to simply continue redirecting Ray perceived colleagues who wanted to hold his feet to the fire—discharging him from the facility if he didn’t cease his harassment—as overly sensitive. Those not inclined to tolerate his disrespect considered those who were willing to overlook it as ‘enabling’ or ‘making excuses.’

Although the facility had policies against harassment, several factors had created a gray area in which Ray had evaded any real consequences. These factors included Ray’s advanced age, infirmity, need for personal care, and questions about his mental status. Disagreement among staff further undermined any consistent plan for holding him accountable.

When ambiguities and ‘gray areas’ empower harassment and intimidation.

When it comes to harassment and intimidation, these and other variables, including the tepid response by this facility’s management about enforcing its policies, can create ambiguity in which opportunistic and bullying behaviors can persist even in overt and egregious cases like Ray’s.

This ambiguity can expand when behaviors are more subtle. For example, the patient whose flattering comments about a nurse’s appearance make her uncomfortable, but which seem intended as complimentary, can create self-doubt about how to respond.

Should I say something? Let it go? Am I overreacting? Are they just being nice? It happened before and I ignored it—can I really say something now? Will my supervisor be annoyed if I throw this in her lap? 

This kind of gray area also creates space in which the intention of hurtful behaviors may be unclear. For example, the patient who says, in an apparently concerned tone to an overweight nurse, “Looks like I’m not the only one who has to be careful about my blood pressure,” or the patient’s son who rubs up against a nurse in a way that feels violating but could plausibly have been inadvertent.

Variability in institutional enforcement and support.

Medical settings typically have clear policies when it comes to harassment related to gender, race, sexual orientation, and so on. But whether and how these policies are enforced varies. So does the extent to which nurses feel empowered to set firm limits and/or involve supervisors in potentially emotionally charged conversations with patients that might create ‘drama’ or upset ‘the customer.’

In our current milieu, awareness has been heightened around issues relating to gender dynamics and the prevalence of predatory, opportunistic, and ‘microaggressive’ behaviors. It’s the perfect time to begin addressing this gray area that has provided a life support system for the kinds of unacceptable behaviors to which nurses have long been subjected.

Addressing the behavior directly may sometimes help.

This doesn’t mean jumping to automatic negative interpretations about a patient’s intentions or motives; it doesn’t mean being punitive or blunting our compassion. Some nurses may worry about overreacting or harming their relationship with a patient. In cases, though, where a patient’s behavior stems from a simple lack of awareness or from motives intended as friendly, speaking up in a nonconfrontational manner intended to elicit a patient’s empathy and understanding is not likely to lead to conflict.

Teamwork is crucial, and real consequences for patients and families.

In those relatively rare cases where this type of limit setting results in aggressive patient resistance, denial, or attacks, it is likely to have revealed deeper dynamics and concerns about which all staff need to be aware and for which leadership may need to respond.

Changing these dynamics isn’t something nurses should have to do alone. It takes teamwork across disciplines and ongoing staff training. It requires agencies and institutions that take these matters seriously and encourage nurses to set limits in an appropriate and professional manner, and which apply real consequences to patients and family members when they disregard these norms.

Scott Janssen is a clinical social worker with UNC Health Care Hospice in Chapel Hill, North Carolina.