Policy Brief: Building resilience, health, and wellness for undergraduate nursing students beyond Title IX and early alert programs.

Issue

Manifestations of stress have serious consequences for nursing professionals beginning with nursing students. [1, 2] One source of stress for baccalaureate nursing students is inappropriate patient sexual behavior (IPSB). [3, 4] Baccalaureate nursing programs have limited response frameworks to provide support to affected students. High levels of stress, regardless of duration or frequency, can affect learning, performance, and retention in nursing programs. [1, 3] Many stressful incidents experienced by nursing students do not meet parameters of existing student support policies, including Title IX or early alert programs since they occur in clinical sites off campus. Repetitive high-stake stressors encountered by nursing students increase risks for deleterious health outcomes. [1–4] Therefore, policy changes at university, state, and federal levels to build resilience, health, and wellness for undergraduate nursing students must be developed and implemented.

Background

Nurses face higher levels of stress with adverse health outcomes compared to other health professions. [2] Stress in nursing has been linked to reduced job satisfaction, increased illness, and poor job performance. [1–4] Furthermore, nursing students who were exposed to more adverse childhood experiences (ACE) showed higher rates of burnout and depression. [5] Developing strong foundations to manage stress early in nursing education may prepare nurses to develop better coping mechanisms, which could subsequently help them to develop healthy habits, decrease attrition rates, and reduce chances of developing stress-related illness later in life [6].

It is well documented that that nursing school can be a stressful experience and that nursing students have more intense stress levels than students studying in other health fields. [4] While there are many sources of stress, one of the more prevalent identified sources in healthcare is inappropriate patient sexual behavior. [3, 4] Johnson and colleagues define IPSB as any “verbal or physical act of an explicit, or perceived sexual nature which is unacceptable within the social context in which it is carried out.” [7]. IPSB encompasses a spectrum of behaviors including: gesturing, giving romantic gifts, making suggestive remarks, propositioning, exposing genitalia, unnecessary touching, with some of the more extreme cases resulting in sexual assault and rape. [8] It is imperative to note that when a patient’s behavior creates a hostile or intimidating work environment for any health care worker, as in its extreme manifestations, IPSB falls under the legal classification of sexual harassment, a form of sex discrimination that violates Title VII of the Civil Rights Act of 1964 [9].

The prevalence of IPSB among the nursing profession is difficult to ascertain due to a paucity of research and a presumption of underreporting. Ranges of reported IPSB in nursing range from 30–90% [10] and the majority of these reported incidents are from female nurses. [11] As nursing is a predominantly female profession, it is logical that female nursing students are a high risk for experiencing IPSB.

When IPSB is recognized as sexual harassment, it can imply patients as adversaries creating a difficult and potentially less effective care environment. Sexual harassment by patients is a significant problem for general healthcare professionals; however, nurses consistently report sexual harassment by their patients more than any other healthcare sector. [8] This is particularly poignant given that we are in the midst of several international campaigns increasing the awareness of sexual assault and harassment. Additionally, the Joint Commission has issued a Sentinel Event Alert on physical and verbal violence against healthcare workers, including sexual harassment, which calls to enforce workplace policies that keep nurses and other healthcare workers safe [12].

The emotional repercussions of sexual harassment include but are not limited to frustration, embarrassment, fear, anxiety, shame, depression, diminished self-esteem, and isolation by the victim. [13] The confusion and self-blame that often accompanies these emotions can then lead to psychological distress. For healthcare providers, inappropriate sexual behavior has been shown to impact ability to function, which can ultimately result in patient avoidance or neglect. [14] This is especially concerning in nursing given the amount of intimate care that we provide. While experienced nurses may have learned over time how to cope with toxic work environments, nursing students may lack the skills to navigate through such patient situations while simultaneously learning how to be a nurse. High levels of stress can affect learning, performance, and retention in nursing programs [1].

Nursing students must attain a unique skill set in their education to establish a foundation of resilience. They must mitigate the negative impact of stressors while managing physical and mental stressors of challenging nursing curricula. Concepts such as resilience, psychological strengthening mental wellness and academic success have been shown to have a pivotal role in the ability to cope with the challenges of nursing education. [15] Cognitive restructuring programs, problem-based learning support from family/friends/faculty, and education programs improving communication have been shown to increase resilience among nursing students [4].

Current Policies

Title IX of the Education Amendments Act of 1972 is a landmark federal law prohibiting sex discrimination in education. This law addresses sexual harassment, gender-based discrimination, and sexual violence. Title IX applies to all programs and related aspects of educational systems. In the 1990s, the U.S. Supreme Court issued three decisions interpreting Title IX to require schools to respond appropriately to reports of sexual harassment and sexual violence against students [9]. Early alert programing supports students and improves student retention in higher education. Some institutions solicit early alerts for social and emotional indicators beyond academic performance, such as drug and alcohol use, personal/family difficulties, and medical/mental health concerns. Early alert systems include any arrangement that provides feedback on a student’s situation – academic, social, or otherwise – allowing early intervention by divisions of academic or student affairs [16].

Closing The Policy Gap

Title IX and early alert systems offer organizational frameworks for identifying and managing specific types of stressors experienced by higher education students. Undergraduate nursing students are exposed to many potentially stressful situations in off-campus clinical settings, including IPSB. This type of incident does not fall within the parameters of Title IX or early alert systems, placing undergraduate nursing students in a vulnerable position that does not encourage a strong foundation of resilience, health and wellness. To address this crucial gap, a support system for undergraduate nursing students must be developed at the institutional level, the accrediting body level, both state and national levels, as well as the curriculum level. The Code Lavender model provides an established and effective framework for delivering emotional support in the clinical setting. Initially intended for patients and families, Code Lavender has evolved into an intervention when challenging situations threaten personal emotional equilibrium of healthcare staff as well. Affected individuals are assisted to meet their immediate responsibilities and process stressful situations through evidence-based relaxation and restoration interventions such as relaxation or breathing exercises, massage therapy, music, Reiki, or other kinds of soothing. [17, 18] Regardless of the specific intervention used, the message conveyed is comfort, caring, support, and restoration. [19] While this framework has been shown to be successful in clinical settings, there is no research demonstrating its effect in educational institutions and more specifically, for undergraduate nursing students. The Code Lavender framework would have the potential to lead to state boards of nursing initiatives to promote psychological first-aid support systems into the accreditation processes for baccalaureate nursing curricula.

References

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9. The U.S. Equal Employment Opportunity Commission (2019) Sexual harassment. Available: https://www.eeoc.gov/laws/types/sexual_harassment.cfm.
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19. Davidson JE, Graham P, Montross-Thomas L, Norcross W, Zerbi G (2017) Code Lavender: Cultivating Intentional Acts of Kindness in Response to Stressful Work Situations. Explore (NY) 13: 181–185. [crossref]