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Iowa Board of Nursing
RiverPoint Business Park
400 S.W. 8th Street, Suite B
Des Moines, IA 50309-4685
Tel: 515/281-3255
Fax: 515/281-4825

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Sexual Misconduct Position Paper
Iowa Board of Nursing

INTRODUCTIONS:

The Iowa Board of Nursing has the legal authority to set the minimum standards for nursing care delivered in the state. Public protection is the Board's primary goal. This charge includes safeguarding the physical, mental, and social well-being of the recipients of health care services as rendered by registered nurses and licensed practical nurses.

This statement on sexual misconduct is issued by the Board of Nursing to convey its commitment to promote an understanding of sexual misconduct and to protect the citizens of Iowa.

Iowa Code § 709.15, addresses the issue of sexual exploitation by a counselor or therapist providing mental health services. The definition of counselor or therapist includes nurses.

Iowa Code § 147.55, Chapter 272C, and 655 IAC Chapter 4, authorize the Board to discipline a nurse for unethical conduct. Unethical conduct in a nurse-client relationship includes, but is not limited to, those acts defined in Iowa Code § 709.15. Therefore, the Iowa Board of Nursing urges all nurses to be aware of the following:

  1. When sexual misconduct occurs, it is almost always harmful to the client whose trust has been violated.
  2. It is the responsibility of the nurse to maintain the boundaries of the professional relationship by avoiding any type of sexual behavior with clients, or any suggestion of interest in sexualizing the nurse-client relationship.
  3. It is the nurse's statutory duty to report any act or omission involving unprofessional or unethical conduct, including sexual misconduct, that may indicate a licensee is unable to practice nursing with reasonable skill and safety. This shall include any conduct which may have a negative influence on the physical or emotional welfare of the client.
  4. When the professional boundary is violated, serious consequences may occur to the client, the nurse, and the nursing profession.

POLICY GOVERNING SEXUAL MISCONDUCT BY NURSES

DEFINITIONS:

I. Sexual contact with a client constitutes sexual misconduct and is a violation of the Iowa Code and Nursing Board rules.

Client: The determination of when a person is a client for the purposes of 655 IAC Chapter 4, is made on a case-by-case basis with consideration given to the nature, extent, and context of the professional relationship between the nurse and the person. The fact that a person is not actively receiving treatment or professional services from a nurse or is not in a health care setting, is not the only determinant of this issue. A person is presumed to remain a client until the client-nurse relationship is terminated.

Sexual misconduct: A specific type of professional misconduct which involves the use of power, influence, and/or special knowledge that is inherent in one's profession in order to obtain sexual gratification from the people a particular profession is intended to serve. Any and all sexual, sexually demeaning, or seductive behaviors, both physical and verbal, between a service provider (i.e., a nurse) and an individual who seeks or receives the service of that provider (i.e., client), is unethical and constitutes sexual misconduct.

II. Sexual Contact Defined: Sexual contact between a nurse and a client refers to any sexual or sexualized behavior, whether physical or verbal, and includes, but is not limited to:

A. Any behavior or involvement with a client, whether inside or outside of the professional setting which:

- may reasonably be interpreted as intended for the sexual arousal/gratification of the nurse, the client, or both; or
- may reasonably be interpreted by the client as being sexual in its intention.

B. Any sexual behavior or involvement with a client not currently receiving care from the nurse which meets any one or more of the criteria above, or which:

- occurs as a result of knowledge derived by the nurse from within the context of a professional relationship,
- results from the exploitation of a client's emotions, trust, or influence in a previous nurse-client relationship, or
- reasonably appears to constitute an abuse of power on the part of the nurse.

C. Actions involving a nurse which would constitute sexual misconduct with a client include, but are not limited to, the following
behaviors:

- any direct, intentional genital stimulation or sexual gratification via oral, manual, genital, instrumental, or other means.
- any manipulation or penetration of any bodily orifice by any means that is not medically indicated.
- any exposure, touch, or manipulation of the breasts, nipples, genital area, buttocks, or anus that is not medically indicated, is not reasonably part of routine care of the client, or is engaged in for the purpose of sexual gratification.
- any medically indicated procedure or aspect of routine care involving the sexual or private parts of the body that is sexualized, prolonged, or altered in order to provide sexual gratification.
- any sexualized comments or gestures, any verbalizations intended to invite or suggest sexual contact or a romantic relationship.
- kissing, fondling, dating, or flirting with clients.

Each of the above actions would constitute sexual misconduct by the nurse, whether or not performed with the client's consent, by the client with consent of the nurse, or with consent of both.

III. Termination of Nurse-Client Relationship: Once a nurse-client relationship has been established, the nurse has the burden of showing that the professional relationship no longer exists. The mere passage of time is not solely determinative of the issue. Because of the varying nature of types of nurse-client relationships, variety of settings, differing practice types, and disequity in power between nurse and client, individual analysis is essential.

Some of the factors considered by the Board in determining whether the nurse-client relationship has terminated include, but are not limited to, the following:

A. Termination of therapy for the purpose of entering into a sexual or romantic relationship.
B. The extent to which the client has confided personal or private information to the nurse.
C. The nature of the client's health problem.
D. The degree of emotional dependence and vulnerability.
E. The extent of the nurse's general knowledge about the client.

1. Some nurse-client relationships may never terminate because of the nature and extent of the relationship. These relationships may always raise concerns of sexual misconduct whenever there is sexual contact.

2. Sexual contact between a nurse and a former client after termination of the nurse-client relationship may still constitute unethical conduct if the sexual contact is a result of the exploitation of trust, knowledge, influence, or emotions derived from the professional relationship.

IV. Assessment and Intervention: Appropriate nursing assessment and intervention includes verbal or physical behavior required for carrying out these functions. Such behavior must be performed in a manner that meets the standard of care appropriate to the situation and does not constitute sexual misconduct.

V. Consent: A client's consent to, initiation of, or participation in sexual behavior or involvement with a nurse does not change the nature of the conduct nor lift the statutory prohibition. The nurse has full and sole responsibility to maintain proper boundaries. Consequently, it shall not be a defense or a mitigating factor that the client was capable of consenting, or that the client does consent, or that the client agreed to, proposed, or initiated the sexual contact or the sexual or romantic relationship.

Pointing to the client's consent or initiation, or making any other attempt to shift responsibility to the client in an effort to avoid full and sole responsibility, provides no defense for nurses who engage in sexual contact with their clients. An example might be a nurse asserting that the client was seductive or manipulative.

VI. Recommendation to Nursing: To further assist its licensees, the Board strongly recommends the following:

A. Nurses should be aware of any feelings of sexual attraction to a client, and should discuss such feelings with a supervisor or trusted colleague. Under no circumstances should a nurse act on these feelings or reveal/discuss them with the client.
B. Nurses should transfer the care of a client to whom the nurse is sexually attracted to another nurse. In addition to recognition that such feelings are neither wrong nor abnormal, nurses should seek help to understand and resolve them.
C. Nurses must be alert to signs that a client may be interested in or may be encouraging a sexual relationship. Any such actions by clients should be reported immediately, and appropriate responses made. All steps must be taken to ensure that the boundaries of the professional relationship are maintained. This could include transferring the care of the client.
D. Nurses must respect a client's dignity and privacy at all times. Nurses should provide a professional explanation regarding of the need for each of the various components of examinations, procedures, tests, and aspects of care to be given. This can minimize any misperceptions a client might have regarding the nurse's intentions and the care being given.
E. Nurses' communications with clients should be clear, appropriate, and professional.
F. Nurses should never employ sexual innuendo when communicating with a client, or use language which may be interpreted as flirtatious, off-color, or offensive.
G. Nurses should not discuss their personal problems, or any aspects of their intimate lives with clients.

VII. Discipline: Upon a finding that a nurse has committed unethical conduct by engaging in sexual misconduct, the Board will impose such discipline as is deemed necessary to protect the public. The sanctions available to the Board are set forth in Iowa Code Chapter 272C and 655 IAC Chapter 4, and may include licensure restriction and limitation of the nurse's practice, revocation, or suspension. There may also be additional civil and/or criminal liability based on Iowa Code chapters 235B (Adult Abuse) and 709 (Sexual Abuse).

Adopted by the Iowa Board of Nursing on February 28, 1996.

The Iowa Board of Nursing expresses thanks to the Washington State Nursing Care Quality Assurance Commission for permission to use their position statement as a model.

Reviewed 1/25/05 - MA