From assault to advocacy: The nurse asked for help. Then she was sexually assaulted.

Author: Ellen Schimmels, PhD, DNP, PMHNP-BC, ANP-BC, CNE, FAAN

While the following case depicts an incident in a Veteran’s Health Affairs (VA) hospital, sexual violence and other forms of workplace violence are universal themes in healthcare, occurring in every setting. Both women and men can be perpetrators and victims of sexual violence. It is critical for nurses to understand their rights and to advocate for themselves and other nurses.

Introduction

Workplace violence has become so common that it is often considered more of an unpleasant part of the job or gets ignored rather than reported. Sexual violence is often included in the broader category of workplace violence, but the unique characteristics and consequences of sexual violence warrant separate recognition and targeted prevention strategies (Kafle et al., 2022; Mitchell, 2021). Up to 60% of female healthcare workers have experienced sexual violence at work, with 73% not reporting it because they feared not being believed or worried they would lose their jobs (Mitchell, 2021).

Nurses have the right to a safe workplace, and this includes protection from sexual violence (Kafle et al., 2022). But healthcare workers, including nurses, are not always protected by enhanced state penalties that often do not specifically address sexual violence, in fact, most states focus on workplace violence generally and vary significantly (Lombardi et al., 2026). For healthcare workers in the private sector, addressing workplace sexual violence requires comprehensive state laws, effective enforcement, and accountability mechanisms. In contrast, VA facilities operate within the federal government, and federal criminal law governs many offenses committed on federal property or against federal employees. Congress therefore has the authority to enact legislation establishing or enhancing criminal penalties, including felony penalties, for assaults against healthcare providers working in federal facilities.

Case Study

When the nurse walked onto the unit that morning, she had no idea she would walk off a completely different person. The shift started like any other. Nearly three years later, she still thinks about that day every day.

The patient was masturbating in front of staff. He repeatedly called her degrading names. W**re. S**t. B**ch. The kind of words that stay with you long after a shift ends. There were witnesses. The nurse reported the behavior to her charge nurse. The charge nurse directed her to the manager. The manager was busy. She returned and explained the situation again, emphasizing the severity of what was occurring.

The manager laughed.

She understood the culture. Keep your head down. Do your job. Don’t make waves. Don’t question authority. She returned to the floor. The patient continued ringing the call bell.

Again. And again. And again. Then he slapped her on the buttocks. Only then did the situation become impossible to ignore.

Police were called. The patient was charged with criminal simple assault and simple disorderly conduct. The assault was not disputed. The report was substantiated. The patient admitted what had happened. The assault was real. Yet the patient remained on the unit without consequences.

The nurse was instructed to finish her shift. She was denied trauma counseling. She was denied meaningful support. She was told that nothing would happen to the patient. She was told that there would be no meaningful consequences. More than once, she was encouraged not to make a big deal out of it.

The message was clear. Move on. Keep working. Finish your shift. Stop talking about it. The only immediate change was that the patient would now be assigned to a male nurse.

That day everything changed. What followed was not simply the aftermath of an assault. It became a journey through reporting systems, workplace violence policies, investigations, leadership failures, retaliation concerns, and institutional silence. At first, the nurse believed she was fighting to address a single incident. Then she started researching.

She reviewed Government Accountability Office reports. She examined workplace violence policies. She immersed herself in the literature on workplace sexual harassment, workplace violence, trauma, leadership, and healthcare safety. What she discovered was even more disturbing. Her story was not unique. The more she learned, the more she realized there were countless healthcare workers with their own version of that event. Different facilities. Different leaders. Different circumstances. The same message. Endure it. Stay quiet. Finish your shift. Keep working.

What began as personal experience evolved into a broader examination of workplace safety, institutional accountability, leadership responsibility, and the protection afforded to healthcare professionals.

Overview of Violence in the Workplace

This account is from one nurse and her experience but also serves as a composite placeholder for the countless nurses, the countless women whose experiences are silenced in systems that are insufficiently equipped to address sexual violence in the workplace. Our brains have a way of trying to be helpful, sometimes looping emotionally impactful phrases like “let him finish” to make meaning or process such an event. Of course, sense-making is even more challenging when it is partnered with institutional betrayal.

Institutional betrayal theory posits that the actions or failures to act of organizations and their leaders can inflict additional harm on individuals who have experienced violence. Rather than occurring as isolated incidents, institutional betrayal is often embedded within organizational culture, manifesting across multiple levels of an institution and reflecting broader systems of power, oppression, and inequity (Dufour, 2024). In the context of sexual violence, these dynamics are particularly salient, as sexual violence represents a form of gender-based violence rooted in persistent gender inequality, discrimination, and social injustice.

Although sexual violence is often grouped within broader workplace violence prevention frameworks, its gendered dynamics, embedded power imbalances, and distinct barriers to reporting warrant dedicated prevention, response, and support strategies that extend beyond standard workplace violence approaches. Rather than being addressed solely as a subset of workplace violence, sexual violence, the spectrum of verbal, non-verbal, physical, and digital behaviors, should be understood as a related but distinct phenomenon requiring targeted policies, specialized training, robust reporting systems, and intentional organizational response mechanisms.

Current workplace violence prevention programs frequently emphasize physical aggression, threats, and de-escalation strategies; however, these measures are often insufficient for addressing sexual violence, which is shaped by gender norms, hierarchical power structures, organizational culture, and systemic sexism. Accordingly, while sexual violence remains a form of workplace violence, its relational and sociocultural complexity necessitates prevention efforts that go beyond traditional frameworks to include leadership accountability, trauma-informed support systems, and sustained organizational culture change (Hauenstein & Schimmels, 2024).

Veterans’ Healthcare Settings

In testimony before the House Committee on Veterans’ Affairs, the U.S. Government Accountability Office (GAO) identified significant deficiencies in the Department of Veterans Affairs’ efforts to prevent, monitor, and address workplace sexual violence (Brown Barnes, 2020). The GAO estimated that approximately 22% of VA employees had experienced some form of workplace sexual violence. Key concerns included conflicts of interest within reporting structures, inconsistent policies, inadequate data collection and oversight, limited accountability for corrective actions, and insufficient employee training. A subsequent GAO review found that the VA had made only partial progress in addressing these concerns and had not fully implemented several recommended reforms aimed at improving employee protection and organizational accountability (Costa, 2022).

More recent research suggests that sexual violence could be even higher and remains a pervasive concern within VA healthcare settings. In an exploratory pilot study of 105 primary care providers across 15 VA facilities, Fenwick et al. (2024) found that 71% reported experiencing patient-perpetrated sexual violence within the previous six months. Follow-up qualitative interviews with VA staff highlighted the need for a fundamental shift in organizational culture, from one that tolerates patient sexual violence to one that prioritizes staff safety and well-being (Fenwick et al., 2025). Participants identified unmet needs across four key domains: training frontline staff to respond effectively to violence in real time, preparing supervisors to support affected employees, establishing procedures and resources for emotional support following incidents, and strengthening reporting mechanisms and follow-up processes.

In another study, participants identified a range of interconnected challenges to addressing patient-perpetrated violence towards female staff and patients at organizational, staff, and patient levels. Organizational barriers included a perceived culture of tolerance toward violence, the absence of formal policies, and insufficient leadership support. At the staff level, challenges included ambiguity in defining violence, concerns about negatively affecting patient–provider relationships and competing workplace priorities. Participants also noted patient-related factors, such as advanced age, cognitive impairment, and psychiatric conditions, which complicated assessments of intent and accountability. To address these issues, recommendations included implementing comprehensive policies and reporting systems, promoting public awareness campaigns to establish behavioral norms, providing education for staff and patients, and offering bystander intervention training (Fenwick et al., 2021).

Sexual violence within VA settings affects not only women employees but also women Veterans receiving care. Recent surveys indicate that 10–25% of women Veteran VA users have experienced sexual violence, with male Veterans identified as the most common perpetrators (Fenwick et al., 2025; Klap et al., 2019). Because VA facilities primarily serve a male patient population and operate within a culture shaped by military gender norms, these environments may be more conducive to the occurrence of sexual violence directed toward women staff and patients (Fenwick et al., 2021).

Unique Problems of Healthcare Settings

Not surprisingly, healthcare workers experience high overall rates of workplace violence (WPV), including physical assault, sexual violence, threats, psychological violence, and verbal abuse. In a recent meta-analysis, Rossi et al. (2023) reported prevalence estimates for WPV ranging from 34.1% to 78.9%, with most studies reporting rates between 50% and 75%. Although sexual violence has received comparatively less research attention, pooled prevalence estimates exceeded 25% in many healthcare settings, with reported rates ranging from 6% to 36.2% (Rossi et al., 2023). Female healthcare workers are disproportionately affected, with nurses reporting particularly high rates of workplace violence and specifically, high rates of sexual violence. Additional risk factors include lower occupational status, limited work experience, and inadequate workplace support (Ajuwa et al., 2024).

These findings should be understood within the broader context of gendered workplace experiences. Nurses make up over 50% of the workforce, the largest in healthcare, with women making up 88% of the nursing workforce (Berlin et al., 2025). For some nurses, lived experience of trauma influences the decision to enter the profession, often shaping their identity (Schimmels, 2025). However, within systems that may inadvertently re-traumatize individuals with prior trauma histories, there is a critical need to strengthen organizational supports addressing gender-specific concerns related to sexual violence among female healthcare workers.

At the individual level, gender identity, gender subordination, and shared experiences of gender-based trauma can significantly shape female healthcare workers autonomy, professional voice, and overall workplace experiences. Hauenstein and Schimmels (2024) argue that systemic sexism reinforces gender-subordinating interactions and fosters organizational cultures in which inequitable treatment becomes normalized, thereby limiting opportunities for meaningful structural change.

Like other forms of workplace violence, sexual violence is characterized by high prevalence, persistent underreporting, and significant consequences for both individuals and organizations (Sahebi et al., 2022). While workplace violence prevention programs often emphasize policies, procedures, de-escalation training, and management communication, these approaches may not adequately address the unique dynamics and underlying causes of sexual violence. Workplace sexual violence remains a global concern, shaped by cultural, occupational, and temporal factors (Debnath et al., 2025). Organizations with clearly articulated and consistently enforced policies tend to demonstrate lower tolerance for inappropriate behavior, whereas environments influenced by traditional gender norms may experience higher rates of violence and lower reporting among survivors (Debnath et al., 2025).

Opportunities for Intervention

The nurse is not interested in symbolic gestures or policies destined to collect dust in a binder. She is interested in meaningful change that protects people. As we tell this story publicly, the goal is not to get attention, recognition, or sympathy. There is nothing glamorous about sexual violence or workplace violence. The goal is simply to tell the truth—honestly, completely, and without embellishment—so that people understand the human impact behind the policies, procedures, and statistics. She could never have anticipated how deep conversations about workplace violence would resonate with her long before they became personally meaningful. The value of patience, guidance, and a willingness to engage in these difficult discussions often exceeds what is immediately visible. Listening to stories like this is one thing; choosing to give voice to them is another entirely. In hindsight, those early conversations carry a significance she could not have fully understood at the time.

Societal Level
Bruschini et al.’s (2025) scoping review of approaches to preventing workplace sexual violence in nurses found no approaches outside of the institutional level for addressing sexual violence out of 3912 records. Comprehensive legal frameworks are essential to prevent workplace sexual violence, protect employees, and ensure accountability. Additionally, comprehensive laws should protect employees from retaliation and ensure effective reporting. Addressing sexual violence against nurses is also a matter of gender equity, as the profession remains predominantly female and disproportionally affected by gender-based violence. Advancing gender equity is an essential yet often underemphasized component of workplace violence prevention. Building on the concepts of organizational and societal sexism, the implementation of gender-sensitive and trauma-informed care requires explicit attention to sexist dynamics at both the unit and organizational levels. As a guiding principle, gender-responsive policies are most effective when grounded in gender-equitable practices that support both patients and healthcare staff (Hauenstein & Schimmels, 2024).

Institutional Level
Institutional support is at the crux of prevention and response to sexual violence. Like workplace violence prevention programs, institutional support is multi-faceted across individual, unit, institutional, community, and societal levels. Literature on institutional support is still emerging but will involve considerable structural changes (Dufour, 2024). As was mentioned in the VA reports, ongoing prevention, monitoring, and addressing workplace sexual violence is inadequate (Brown Barnes, 2020; Costa, 2022). Approaches addressing organizational culture, infrastructure and work environment, leadership, education, and reporting are crucial (Bruschini et al., 2025).

Unit and Individual Levels
At the unit level, meaningful inclusion of female staff as key stakeholders and decision-makers in identifying and addressing unhealthy work environments reinforces their roles as professional equals and ensures that solutions reflect gender-sensitive approaches. In contrast, unit- and organizational-level policies that inadvertently permit or fail to address bullying, incivility, and other forms of workplace violence may contribute to compassion fatigue, as well as secondary and vicarious traumatization among healthcare workers. Reporting, education, and nurse specific approaches to coping or reacting to such incidents, with simulation-based training, de-escalation, and self-protection training is used in 62.5% of approaches (Bruschini et al., 2025). Unit and individual level approaches often focus more on the person who is being abused and are more reactive than proactive in nature. One innovative approach at the individual, unit and organizational level is using more cameras including testing body cameras to increase safety, but reinforce ethical concerns (Dean, 2023).

Conclusion

Sexual violence receives insufficient attention when it is folded into broader workplace violence categories. While workplace violence encompasses threats, verbal abuse, physical assault, and other aggressive behaviors, discussions in healthcare frequently emphasize sexual harassment rather than the broader continuum of sexual violence, potentially limiting recognition of its unique impact on nurses. When that happens, the unique nature of these experiences, the additional barriers to reporting them, and the need for targeted prevention and response strategies can become obscured. Accordingly, sustained attention to both patient- and staff-related gendered attitudes and behaviors is critical to effective workplace violence prevention, particularly in addressing sexual violence within healthcare settings.

While there are several organizational, unit, and individual level sexual violence responses, most are reactive rather than preventive, and there are no standardized legal or interorganizational collaborative responses (Bruschini et al., 2025). The hope is to encourage a larger conversation and create space for other healthcare workers within the VA and outside of the VA to share their experiences and to truly work towards prevention of sexual violence in the workplace. Understanding the true scope of the problem becomes essential for meaningful policy and organizational change. Nurses should be educated appropriately on hospital policies against WPV and be encouraged to report any incidence.

What no one could have known that day was that years later, the nurse would still be here. Even though this still wakes her up at night sometimes, she’s still a nurse. She’s still caring for patients. She’s still advocating for safer workplaces. And she’s still speaking about what happened. She’s telling this story. If sharing this experience helps even one healthcare worker feel less alone, encourages one leader to take workplace violence more seriously, or prevents one person from experiencing what she experienced, then it will have been worth it.

Acknowledgement: The author gratefully acknowledges the nurse who contributed her personal and professional experiences to this manuscript, and who wishes to remain anonymous. Her courage and bravery in sharing her experiences have made it possible to bring greater understanding to a story that might otherwise have remained untold.

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