Nursing Students’ Experience of Sexual Harassment During Clinical Practicum: A Phenomenological Approach

Kim, Mijong · Kim, Taeim · Tilley, Donna Scott · Kapusta, Ann · Allen, Denise · Cho, Ho Soon Michelle Associate Professor, Department of Nursing, Hannam University, Daejeon Professor, Department of Nursing, Daejeon University, Daejeon, Korea Professor and Vice Provost for Research and Sponsored Programs, College of Nursing, Texas Woman's University, Texas Associate Grant Program Director, Texas Woman's University, Texas Project Coordinator, Texas Woman's University, Texas Professor, College of Nursing, Texas Woman's University, Texas, USA


INTRODUCTION
Clinical practice is essential for nursing students to improve clinical competency.Nursing students perform nursing activities close to patients.It has been reported that nursing students are easily exposed to sexual harassment during clinical practicum [1].Sexual harassment in nursing is an unacceptable international phenomenon, yet it is widely reported in the literature [1][2][3].It has been reported that 30 to 72 percent of registered nurses [4,5] and 40 to 58 percent of nursing students [1,2,[6][7][8] experienced sexual harassment in the clinical setting.Considering that sexual harassment is only partially reported, sexual harassment experienced by nursing students could be much higher [3,9].
Causes of sexual harassment of nurses are not clearly understood yet.Nursing by its very nature inherently involves working closely with patients physically and emotionally.Patients may misread basic nursing care such as daily hygiene assistance as a sexual signal.Nurses are often stereotyped as sex objects which can also contribute to the problem [10].
Definitions of sexual harassment usually describe behaviors or words directed at a nurse that are sexual in nature.Such behaviors or words are unwelcome and offensive.They directly or indirectly threaten a person's ability to do their work [11].In most publications, sexual harassment is referred to as a workplace problem that causes shame or humiliation and impairs nurse's ability to perform his or her work effectively [4,5].
Experience in clinical practicum is an integral component of nursing education.Many nursing students have a positive clinical experience that is free of sexual harassment, although most students report experiencing some form of sexual harassment [6].Nursing students who feel powerless are much less likely to challenge inappropriate behavior, including sexual harassment [12].
Sexual harassment experienced by nursing students is known to negatively impact not only their physical and mental health, but also their relationship with peers and patient care [10,[12][13][14].Nursing students have reported depression and sadness from sexual harassment, difficulties in concentrating on studies, and decrease in academic performance in practice [2,8].Nursing students who were harassed sexually may lose self-confidence and self-esteem.They may decide to quit their nursing career or transfer to another profession.This may hinder their socialization as professional nurses [6][7][8].Therefore, during the period of clinical placement, they should be considered and protected as vulnerable [7,[10][11][12][13][14].It is necessary to establish strategies to lead to nursing students' clinical experience positively.To do so, the first step is to identify students' experiences of sexual harassment during clinical practicum.However, research reports on students' experience of sexual harassment are insufficient.
Most studies that dealt with the subject of sexual harassment of nurses and nursing students have been largely limited to quantitative research.Researchers have focused on how much proportion of nurses and nursing students experience sexual harassment.They have described negative physical and mental symptoms after avoiding sexual harassment.Thus, there is a pressing need to understand participant's lived experience beyond quantitative data.Qualitative studies using in-depth interviews and hermeneutics phenomenological studies are more appropriate to show what victims of sexual harassment have experienced and how they feel and respond.Phenomenological research can provide a greater understanding of physical, mental, and behavioral effects of sexual harassment on nursing students.Heidegger's hermeneutics phenomenological approach is a method with many advantages for analyzing conceptual and lived experiences [15].According to Heidegger, human beings are active participants within experiences and find purpose and meaning within the world.For nursing, Heidegger's concept of embodiment acknowledges the interconnectedness that participant's experience shows as a background which helps us further understand the participant [16].This interpretive phenomenology study was to explore the lived experience of sexual harassment among nursing students during clinical practice.'Interpretive phenomenology', also referred to as 'hermeneutics', is to describe, understand, and interpret participants' experiences [15].Interpretive phenomenology maintains that knowledge of an experience cannot be had without an understanding of the context [17].It aims to offer insights into how a person, in context, makes sense of an experience [14].This methodological approach has not yet been used in studies on sexual harassment of nursing students.However, it is expected to provide profound insights.
Beyond a quantitative understanding of sexual harassment, by vivid listening to expressions expressed by participants, nursing educators will be able to fully understand them and make efforts to provide a safe educational environment for nurses.
Therefore, an interpretive phenomenological approach is suitable for research that aims to understand and interpret participants' experiences and to determine the meaning of these experiences.Regardless of which specific phenomenological approach is undertaken, of central importance is 'the significance of thinking phenomena logically while doing phenomenology' [16].Thus, the purpose of this study was to identify the experience of sexual harassment in nursing students during clinical practice.

Study Design
An interpretive phenomenological qualitative approach following philosophical assumptions espoused by Heidegger was used for this research to gain a rich understanding of contextual experiences of participants [18].It is useful to use this methodology because this method is based on a comprehensive understanding of context when exploring experiences of sexual harassment during clinical practice of nursing students.

Setting and Participants
Participants in the study were recruited from two universities in a metropolitan city in South Korea from December in 2016 to May in 2017.The recruitment of participants in this study was announced in online bulletin boards and offline classrooms.Students with experience of sexual harassment who were willing to participate in an interview were invited to come to the researcher's office or do a phone interview.Data were also collected by snowball sampling.All potential volunteers were provided with a description of the study.Sampling criteria were as follows:  Nursing students who had experienced clinical practicum for at least one semester. Who agreed to participate and to be interviewed in this study. Who experienced sexual harassment directly during clinical practicum.The eligible population consisted of nursing students who had completed a clinical practice at one of two universities in South Korea.There was no requirement that the sexual harassment should be reported.Those who met the inclusion criteria completed the informed consent process and completed the interview with one of two researchers.
At first, 14 students were interviewed.However, one student was excluded from the final analysis because she did not experience harassment herself.She only talked her colleagues' experiences.

Ethical Considerations
This study was approved by our Institutional Review Board before beginning participant recruitment (IRB No. 16-03-11-0822).The protocol was followed to protect all participants.Due to the risk of emotional distress, an experienced therapist was available to participants during the study time period.Participants were informed that the counselor was available to them if needed.None of these participants requested to meet with the therapist.Interviews were audio-recorded and transcribed by the primary investigator (PI).Transcribed interviews were translated into English by the PI and a co-researcher.Both speak English and Korean and have experience as nurse educators.

Data Collection
Interviews were conducted either in person or by telephone by one of two interviewers, one of whom was the PI.These interview questions were developed by the PI following preliminary work on the topic of sexual harassment of Korean nursing students [6].All interviews were conducted in Korean.Each interview lasted an average of 45 minutes.All participants were asked at the same four basic questions: "Please describe your experience of being sexually harassed in clinical practicum.""How did you respond when it happened?""Please describe how this experience has influenced you.""What are your expectations of the clinical site or nursing school to protect participants from sexual harassment in clinical practicum?"The interviewers encouraged participants to expand their experiences during interviews.In addition to these above four main questions, we let them share whatever they wanted to say about sexually harassment in clinical practicum.

Preparation of Researchers
All researchers were trained in how to conduct a qualitative study.Researchers self-checked their knowledge and abilities of qualitative research methods before conducting this research.They participated in this study if they were confident.All researchers have attended workshops on qualitative research methods several times.Four of six researchers in the study have taught the practice of nursing students for more than 20 years.Two are not nurses.However, they are experienced in analyzing and performing qualitative studies.The two researchers who interviewed participants have been conducting research consistently on the safety and effective environment of nursing students' clinical practicum.

Data Analysis
Each interview was transcribed by the PI and a co-researcher, from Korean spoken by participants into English.Both PI and the co-research speak Korean as their primary language.Although portions of transcriptions were not grammatically correct, the research team made the decision to use the original translations without making grammatical corrections.This seemed to more accurately capture the essence of the participants' thoughts.
Data analysis for this study was completed using the seven-step approach.These seven steps used in phenomenological data analysis described by Diekelmann, Allen, and Tanner [16,19,20]

Reliability and Validity in Qualitative Research
Reliability and validity in qualitative research are assessed by trustworthiness which is evidenced by faithful descriptions.The criteria for trustworthiness consist of credibility, transferability, confirmability, and dependability.According to Lincoln and Guba's criteria for trustworthiness, this study strived to increase reliability and validity [21].
Credibility indicates how confident the qualitative researcher is in the truth of the research study's findings.The raw material obtained from participants of this study was read repeatedly and checked.Participants' expressions were collected 'as is'.
Transferability indicates how the qualitative researcher demonstrates that the research study's findings are applicable to other contexts.In this study, participants with ability to express their experiences were selected in the process of participant selection.Data were collected until data were saturated.
Confirmability is the degree of neutrality in the research study's findings.In other words, it means that findings are based on participants' responses without any potential bias or personal motivation of the researcher.Because the research processes and results were liberated from all prejudices, we were able to exclude prejudices or prejudices arising from the knowledge or experience of us.We also limited relevant literature review advance so that the analysis process would not be affected.
Finally, dependability is the extent that the study could be repeated by other researchers and that findings would be consistent.In other words, if someone wants to replicate this study, he/she should have enough information from this research report to do so and obtain similar findings as this study.A qualitative researcher can use inquiry audit in order to establish dependability.To ensure consistency of data, the research was carried out according to the analysis process in seven steps described by Diekelmann, Allen, and Tanner.Continuous comparability of data was maintained for analytical thinking about topics and categories found in the data.Therefore, this study sought to increase reliability and validity in terms of credibility, transferability, confirmability, and dependability.

Demographic Characteristics of the Participants
Data of thirteen nursing students were analyzed.The data for the 13 participants are shown in Table 1.All incidents of sexual harassment described by participants came from patients.No sexual harassment by physician or hospital staff was described.Most (85%) of them were senior students.Only 15% of them were junior students.Of a total of 13 participants, eleven (85%) were female students and two (15%) were male students.

Themes and Meaning Units
Table 2 shows themes and meaning units.Meaning units emerged from the data.These twelve meaning units were situated within three main themes: increased vulnerability for nursing students, weight of obligation, and consequences.

 Increased vulnerability for nursing students
The concept of increased vulnerability for nursing students comprised themes of unprepared to respond, lack of education, unsure about when behavior crossed the line, and power differential for students.

1) Unprepared to respond
When faced with inappropriate behavior, five participants stated they did not know how to respond.One participant described this feeling as "just standing there without knowing what to do."Others described feeling surprised about inappropriate patient behavior.One described that she was taught to expect that kind of behavior.Some participants were not satisfied with their responses to a patient's behavior.As incidents happened so quickly, they could not respond appropriately.One participant ex- pressed regret for not being able to cope properly at the time.Now that she has more experience in clinical practice, she has shown confidence to better cope with the patient's harassment.

Because my response was immature at that time, I felt foolish. [P1]
It was creepy and I was disgusted.I couldn't say anything because I was so surprised.I stepped away.
[P5] I've never experienced such a thing before.I thought I should have taken care of myself then, but there was no way at that time.[P3] At that time, I was just standing there without knowing how to respond to it.[P5] Because student nurses have a lack of experience to deal with unexpected circumstances verses experi-enced nurses.[P14]

2) Lack of education
The theme of 'lack of education' is distinct from, but related to, the theme of 'unprepared to respond'.While the meaning of unprepared to respond seemed to be more about being personally unprepared, the meaning unit, lack of education, reflected participants' frustration that there was no formal training or education to prepare them for an appropriate response to sexual harassment.

And I don't know what actions we need to take to the nursing staff and faculty. [P10]
Since we face various situations in clinical practice, we cannot be trained in all kinds of cases in advance.But I think we should be prepared for the basic preparations against sexual harassment when we care for a patient in clinical settings.Especially at least when dealing with psychiatric patients.

[P10]
At the orientation hosted by the school, the instructors told us not to receive any gifts or foods from the patient, but nothing was mentioned about sexual harassment.[P14] Some participants reported a desire for the hospital to provide training or written material on how to properly handle sexual harassment by patients.Participants said reviewing case study scenarios would be helpful.They also suggested that learning strategies to cope after an incident would be beneficial.Participants stated that, although their university mentioned inappropriate behavior or sexual harassment, it was only mentioned that students should be careful, which was very superficial.A participant said the school's orientation taught them not to provide contact information to patient or accept gifts or food from patients.However, it did not provide further guidance.Participants said the hospital should have informed students about protecting themselves from sexual harassment.Some of them felt that they should have been clearly made aware of patients known to harass nurses or nursing students.A participant believed that if such warning had been provided, she would have felt prepared to respond.
They discussed that if he behaved like this repeatedly, he won't be able to stay there any longer.....However, there was little consideration for nursing students.We expected that the hospital would warn students that we should be more careful when we go to the hospital.We were sorry that the hospital did not say anything.[P9] Since there are also cases that the patient asks for contact information of the students, professors instruct nursing students not to give our contact information and report it to them immediately.......But nurses should have mentioned patient's problematic behavior to students before they start their work.Nurses knew all about the patient's behavior directly and indirectly.[P14]

3) Unsure about when behavior crosses the line
In practice, nurses struggle to determine whether patients' actions are intentional or unintentional.Even the most experienced nurses have difficulty in recognizing sexual harassment [11,22].Participants described difficulty in deciding when patient behavior crossed the line into sexual harassment.When asked about their experience, some participants felt unsure about how to define sexual harassment.

I might be sexually harassed without noticing it.
There might be many things that were actually sexual harassment to me while I didn't quite understand.When I heard something strange, it was better not to understand.

[P4]
A participant spoke of an experience in which she did not recognize a patient's inappropriate comment while other patients and visitors identified it as harassment.Another participant questioned whether the patient's behavior constituted sexual harassment, although some of her classmates readily labeled the patient's behavior as inappropriate.She was also unsure about whether to report the problematic behavior to her professor.

I wonder which range of action should be determined to sexual harassment. [P10]
He spoke frankly but improperly.We thought he was sneaky.It could have been almost sexual harassment.[P2]

4) Power differential for nursing students
Sexual harassment generally occurs in relationships of unequal power [23].Participants in this study perceived a hierarchy in which they felt more susceptible to sexual harassment and less empowered to challenge problematic behavior.A participant stated it clearly when she said, "I think patients behave more harshly because I am a student, not a nurse".This power differential existed between participants and their patients as well as between participants and the clinical setting.Participants described feeling obligated to preserve the relationship between the hospital and their university.Thus, they were hesitant to raise difficult issues such as sexual harassment.
Nursing school also does not want conflict with a hospital.I mean... school is in a position to ask for sending nursing students to a hospital.The school doesn't want to make it difficult with the hospital.
[P12] I think it is necessary for patients to behave in a polite manner to nurses and students.They should treat her as health care professionals instead of seeing them as sexual targets.[P12].
Another patient said the old man had acted like this before in front of the nursing students.

" [P3]
The nurse has an image of angel and can always be seen as an image of kindness.Students are more vul-nerable than nurses and are treated roughly.[P5].
It is very difficult to speak firmly to patients as a nursing student.[P6].
But I couldn't express the unpleasant feelings to the patient.As I was a nursing student, I thought it is a nursing student's responsibility to bear the patient, so I had to endure whatever without showing my uncomfortable feeling about the patient.[P11].

 Weight of obligation
The theme of weight of obligation comprised meaning units, balancing self-preservation with obligations to patients, shame, and feeling responsible for preventing the harassment.

5) Balancing self-preservation with obligations to patients
Participants seemed to struggle with the idea that defending themselves might cause harm to patients.They felt that any kind of response to harassment might interfere with their obligations to patients.Some voiced concerns that responding to sexual harassment by patients might hinder patient care.Some participants said that they thought responding to harassment might make their patient's condition worse.Participants felt they lost rapport with their patients after responding to harassment.Another participant described feeling that, as a student representative of her school, she should not display any signs of being upset while working in the hospital.Alternatively, participants described emotional, mental, and sometimes physical impact of harassment.One participant described her fear of a specific patient.Another one described that she was distracted by her worries of experiencing further harassment to the extent that it interfered with her ability to concentrate on patient care.
It happened with my excessive kindness to patients.I used to talk and act friendly toward the old person before.I am still kind to elderly women.But I feel nervous when I take care of the elderly male patient.[P2] I feared the patient.He was a violent patient and I was a nursing student who had to take care of him.What can I do with such a patient?....I realized a nurse who cares for a sick people may be a vulnerable person who can't be upset in the hospital.I can't cope with the patients firmly.[P6] I thought that my words could hurt their mental condition and I was unable to speak strongly to a patient with mental illness.I was just always looking for where the patient was during clinical.I talked briefly when I faced him.But I tried not to make a situation with him and me.I had already taken courses in communication.I practiced how to talk to patients.But it was difficult for me to talk to a patient who harassed sexually in the clinical situation.[P9]

6) Shame
Shame is closely related to the meaning unit of balancing self-preservation with obligations to patients.It was a common experience for participants.Almost every participant described feeling shame during and after an incident of being harassed by a patient.Some of them felt disgusted, hurt, and angry after an incident.Some of them felt that they could not share their experience with anyone.Another one told a story about a friend who had been sexually harassed by a patient without reporting the incident because "She didn't want to explain and show the disgusting behavior again in a formal channel."Another student who had previously experienced inappropriate patient behavior did not want to report a subsequent incident.
It brought shame on me.I couldn't even tell my friend.It happened and I was ashamed of myself.I didn't remember anything at the time and I felt desolate.

[P5]
At the moment that I was hurt, I was so embarrassed, and I just stood silently without doing anything.

[P12]
Everyone was surprised when he asked if I slept with my boyfriend.I felt ashamed and embarrassed, but it was not a big surprise to me because I had already heard of a strange patient.I just thought, "Ah, this is the guy I heard.

[P9]
It would make me awkward and ashamed to tell the faculty and nursing staff again.[P2]

7) Feeling responsible for preventing the harassment
Participants described that they felt responsible for preventing sexual harassment by patients.They described that they needed to know which patients might harass them so that they could prevent the behavior.They said they need to know what kind of kindness they gave the patient, or what kind of clothing they wore, led to sexual harassment.Some of them described that effective communication with patients could stop harassment from occurring.A participant talked about one of her experiences with a patient who persistently asked for her contact information: I thought it happened because I always smile to every person, especially patients.At that time, I decided it was not a situation to talk while smiling.I had a slight frown on my face and expressed my displeasure.I said, "By the regulations and policy, I cannot let you know my phone number.Please stop it".With my resolute expression and firm voice, the patient did not do such a thing anymore.[P7] Communicating with a patient also helped prevent/ lessen sexual harassment for another participant.One student described a patient who was telling sexually nuanced jokes.When she told the patient that it was offensive, the patient stopped telling similar jokes.
If I hadn't focused on communicating with him, I might have had to listen to sexually harassing things from the patient.[P2] I recommend that students should be given information to dress with care during the clinical practice.Wearing a white or skin-colored sleeveless t-shirt under the uniform is good

. [P2]
There were male students in our team in clinical practicum.One of them was a tall muscular guy.Lucky, I've been with him almost every practice.The problematic patient seemed to be calmer and nice whenever the male nursing student showed up in the ward.It was helpful to prevent sexual harassment, although I know it is not a real solution.[P4] Sometimes this information on potential sexual harassment sources comes from senior students.For example, which facilities we should be especially careful of, not to become a victim of sexual harassment.It may be helpful for us to cope and adapt to the clinical setting and to prevent this kind of unhappy situation.
[P4]  Consequences The theme of consequences comprised impact on patient care, fear of what might have happened, fear of repercussions, long term impact, and peer support.

8) Impact on patient care
For the meaning of impact on patient care, some participants described avoiding patients or delegating tasks to peers to avoid being alone with a patient.Almost every participant mentioned avoiding certain patients.Some of them cited that fear and lack of concentration as reasons why they avoided specific patients.They also used different strategies to avoid patients.A participant said he asked one of his peers to check a patient's blood pressure so that he could avoid seeing that patient.Another one said that she would find out where a patient was when she checked in for her shift to avoid him.The downside to that strategy was that it isolated her from her peers.I certainly recognized he was a man to be wary of.I focused on how I had to face him all day.I could no longer concentrate on my clinical practice.[P3] I didn't want to go to the room anymore.I asked my friend to measure the blood pressure of the patient.[P5] So I try to avoid possible situations as far as possible.As a result, I can't concentrate on my practice.The professors tell us to work with the patient to identify their problems.But after I've experienced sexual harassment, I avoid the patient.[P12] I am just concerned about my immature actions with patients in relation with the clinical training.I just think that it is better to avoid those patients who caused trouble for us.

[P14]
As soon as I entered the ward in the morning, I found out where the patient was to avoid him.I was scared and frightened.I was away from my companions because I was avoiding the patient.On reflection, it is regrettable.Was it the best way in the situation?I couldn't say anything in front of him.[P8]

9) Fear of what might have happened
Some participants experienced incidents in which they wondered how the experience might have different or worse outcomes.In one incident, a participant had her picture taken by a patient without her permission.After the picture was deleted and the patient was discharged, she continued to contemplate the patient's intention for the picture and what would have happened if she had not caught the patient.When a participant experienced inappropriate comments from a patient, her friends worried that the more she avoided, the more likely the patient would suffer due to the lack of care.Subsequently, she changed her strategy and decided to spend more time with the patient.But after answering some personal questions to appease the patient, the participant felt fearful that the patient might find her or contact her.
When I talked to him, he asked me questions about my personal life."Which preschool, elementary school, and middle school did you go?" "Which church do you attend?"I felt like I was being investigated by him.I tried not to answer.But I answered some of them because he was asking too much, it is frightening to think now.What if he finds me and contacts me?[P8]But obviously I was offended and angry.Putting a camera to my face without any excuse and taking a picture of me... What was his intention?If he got my picture..

. I hate to think what might happen. [P7]
A male classmate happened to pass by and said to him, "What are you doing?"The patient huddled back to his bed.If he didn't help me... What might have happened to me?I suddenly thought I might be a victim of violence by a patient.It's best to be careful and avoid it.[P12]

10) Fear of repercussions
Only five participants formally reported the harassment they experienced.Some explained that they thought reporting the harassment would not help.They thought that it could even have a negative impact on the faculty or hospital staff.Participants feared that hospital staff might have the perception that the participant was a "troublemaker" which might negatively affect their practicum grade.Other participants described feeling that reporting would be fruitless and that nothing would change even if they reported.Thus, they did not report the harassment.A participant suggested that nurses should be willing to listen to a student's experiences without having prejudgement.Other participants said that students should not be penalized for reporting.One participant said that students should be able to take one to two days of leave without negative feedback or effect on their grade.
What do they think of me?How do nursing staffs evaluate me?Does this episode influence my academic score?Does my university see me as a trouble maker?Did I provoke him?I don't want to provide things to be talked about by people because it might hurt me again.[P1] Usually, victimized student does not want to reveal this fact except to their close friends.If anything happens to us, we should report to the nursing staff or professor.However, after reporting, we do not expect the condition of clinical practice will improve.Most of them feel bad by themselves and forget it....Even if we tell the nursing staff, it won't improve hugely.They almost always focus only on the patient.Or if we report it to nursing school, there is nothing to change.When I report to the nursing school, it can give the impression to my professor that I'm a trouble maker.We are afraid that it may have a negative impact on academic score as well.So, we commonly pass it by without reporting to school.[P11]

11) Long-term impact
Participants continued to have emotional or mental effects, including fear, for weeks after experiencing harassment by patients.A participant stated she was unsure if she had yet recovered from her experience.She also described wondering if she could ever be a good nurse.Some participants compared the trauma of physical and verbal harassment.A participant did not have any physical injuries as a result of his experience.However, he talked about the effects of harassment by a patient.Another participant's perspective was that physical harassment left "...bigger and more serious scars..." on victims' emotions than verbal harassment.I felt like I was going to die for two weeks.I don't expect that feelings of being victimized can recover through formal routes.So, I am anxious about my future.What will happen to me in the future as a nurse?I am concerned that I may not be a good nurse.

[P1]
At that time, I should have taken a healing break for one or two days to rebuild my mind.I don't know whether I will recover from that trauma.Trauma... Yes,.. It's kind of psychological trauma to me.In my point of view, some needs further counseling or treatment depending on the severity of experience.Once I've been sexually harassed, unpleasant feelings will remain like a scar in my mind.I mean, once you get hurt, it's a vile feeling and a bad feeling.For that reason, I become more defensive when I approach patients.I think it is one of those defensive habits that I explain nursing procedure in detail to patient before practice.[P11] I mean, if I suffer, it'll be uncomfortable, and this feeling will last for a long time.[P12]

12) Peer support
There were several ways nursing students relied on their peers to prevent, mitigate, and cope with sexual harassment by patients.Participants received advice or warnings about specific patients from their peers.Female participants had male peers come to their defense when an incident occurred.Some participants said they talked with peers to recover from their experience.

Even if I had an unpleasant experience, I wouldn't expose it to anyone except friends. [P2]
A team mate and I tend to share something good or bad things during practice.We support each other.Friends, especially members of the same team, are the best medication for each other in clinical practice.[P7] We comforted her after we finished the day.When this happens sometimes in practice, we talk with each other and try to relieve stress and try to forget it quickly.[P10] At school, prior to the training, the instructors tell us not to gather together inside the hospital, but in order to secure students' safety, I think it is essential to form a group of two during clinical training.[P14]

DISCUSSION
Participants in this study perceived a hierarchy in which they felt more susceptible to sexual harassment and less empowered to challenge problematic behavior by patients.Specifically, participants in this study stated they were not trained about how to recognize or address harassment.Many described difficulties in recognizing when behavior crossed the line into harassment.This is often a difficult distinction for seasoned nurses to make [22].It seemed to be even more difficult for nursing students.Preparing students early to recognize and effectively address sexual harassment is recommended [1,6,24].In addition to training for students, results of this study indicated that hospital staff and faculty might also benefit from training about how to recognize sexual harassment and how to assist students who experienced harassment.
When participants reported their experience of sexual harassment during clinical practicum to the institution, they described an overwhelming sense of responsibility to their patients and to the university they represented.They described a willingness to preserve patient rights and the university's relationship with the clinical site, even if it was at the expense of their own rights.Such a phenomenon is an obstacle to reporting sexual harassment in clinical field and solving problems.The seriousness of sexual harassment cannot be fully revealed either [8,25,26].Under-reporting of these experiences minimizes the nature and extent of the problem.It prevents the identification and development of strategies to prevent and manage sexual harassment of nursing students.In fact, some nursing students considered that the definition of sexual harassment was ambiguous.They accepted it as part of their work [25].Some studies noted that nursing students reporting episode of sexual harassment were dissatisfied with the outcome [26].Results of the present study suggest that it is necessary to develop a sexual harassment prevention education program for nursing students and establish a systematic reporting system.
Training about sexual harassment should include assertiveness content.That is, participants need to understand how to respectfully yet firmly interact with patients in a way that preserves rights of all parties, including themselves [1].Some participants voiced concern about being considered a "trouble maker" if they reported sexual harassment to their institution.
Participants in this study described a very precarious situation in which patients who harassed them did not face consequences for harassment.Both students and patients who harassed them seemed to be aware that reporting was futile without resulting in meaningful change.This highlights the need for a reporting system so that participants can receive appropriate services when they experience harassment [7,25,26].For example, faculty who are aware that a student was harassed can engage in thoughtful and informed debriefing with their clinical group about sexual harassment immediately following clinical practicum.Participants described the importance of peer support to them after experiencing harassment, consistent with results of preceding studies [1,24].Peers who have the same experience are the most powerful sources of resilience for participants who have been hurt in clinical practice.
Consistent with results in the current literature, male participants in this study also experienced sexual harassment by patients [6].Like their female counterparts, male students described struggling with mental and emotional sequelae of their experience, although they did not describe feeling the fear their female colleagues described.Male students voluntarily intervened when they saw a female peer was being harassed.Having a male student in the clinical group was thought by at least one participant to be able to mitigate harassing behavior by patients.These findings illustrate the need for further research on experiences of male students.
Finally, results of this study are consistent with recommendations by previous researches to have assertiveness training for nursing students and nurses.Both male and female nurses tend to have a passive communication style as part of their caring role [27].This sympathetic, understanding role has been traditionally taught and expected from them [28].Helping students respond to sexual harassment in an assertive way can attend to their concerns about balancing their own rights with their obligations to patients.
Sexual harassment has a great meaning in the field of women's health care.In particular, it is the basic right of nursing students to learn in a safe clinical setting.It is easy to overlook its impact on nursing education because what is perceived as sexual harassment can be vague and personal.In the context of clinical practicum of nursing students, we tried to derive a lived and vivid experience of sexual harassment.Through this study, we hope to hear and feel experiences of victims of sexual harassment among nursing students.Furthermore, we look forward to a thorough overhaul in an environment safe and free from sexual harassment.

CONCLUSION
Findings of this study provide important insight into perceptions of nursing students about their experiences of sexual harassment.To alleviate effects of sexual harassment, procedures for reporting harassment should be established by hospitals and universities.In addition, both institutions should provide training that is standardized and completed by nursing students before they begin their clinical practice.This training should cover response and communication strategies and reporting procedures.It may also include information on continuing patient care with prevention strategies and dealing with special cases such as mental illness.Prevention and response training should also be completed by supervisors as they are most aware of the environment in which nursing students are practicing.Supervisor training could also include strategies for introducing participants in a manner that gives them the same perceived authority as nurses within the clinical site.
As peer support was recognized as a valuable resource in this study, universities could establish or encourage nursing student support groups in which students can have debriefing time with each other and a faculty supervisor.Universities should also strongly consider offering counseling services to nursing students on whether they have been victims of harassment or have had indirect experiences such as witnessing a harassing event.
Consistent with the current literature [3,4], these participants experienced harassment primarily by patients.None of these participants described being harassed by someone other than a patient.This might be an artifact of the interview guide which asked specifically about sexual harassment by patients.Future studies of this type should clearly identify all perpetrators of harassment experienced by participants, including patients' family members, hospital personnel, and university personnel.
[P3] I didn't get physical injury.It certainly didn't affect or harm me physically, but emotionally… and psy-chologically….The words flew into my heart, flying like an arrow.It ruined my condition all day.[P5] Physical sexually harassment leaves bigger and more serious scars in victim's heart than verbal sexually harassment.[P4]

Table 2 .
Themes and Meaning Units