Introduction

It is a myth to think that sexuality does not exist in organizations (Burrell, 1984; Hearn et al., 2005). Sexuality, like gender and power struggles, widely pervades organizational life (Fleming, 2007). Sexuality is far from being a marginal organizational issue, and is “alluded to in dress and self-presentation, in jokes and gossip, looks and flirtations, secret affairs and alliances, in fantasy, and in a range of coercive behaviors” (Pringle, 1990, p. 162). As such, sexuality can be seen as inherent to social interactions in the workplace. Consequently, issues concerning sexual boundaries between actors, up to boundary violations, may occur, leading to misconduct and harm to individuals (Alpert & Steinberg, 2017; Cline et al., 2018; Greve et al., 2010). Particularly healthcare organizations appear to be susceptible to sexual boundary violations (Clemens et al., 2021), defined as “harmful and exploitative sexual transgressions in the professional–client relationship” (Kröger et al., 2022, p. 1). The inherent power inequalities between patients and healthcare professionals imply that sexual conduct between them cannot be consensual (Hook & Devereux, 2018), and research demonstrates that sexual boundary violations are frequently underreported in healthcare (Kröger et al., 2022).

When sexual boundaries are crossed, organizations typically respond in retributive ways. That is, by identifying and sanctioning the individuals responsible and establishing measures to avoid future violations, in an attempt to define and secure a professional work environment (Epstein, 1994; Norris et al., 2003; Rawwas et al., 1994). These retributive organizational responses are problematic for various reasons. They appear to be ineffective as potential perpetrators do not respond to them (Pope, 1990). Additionally, the fear of allegations of sexual boundary violations as well as the retributive responses make healthcare professionals reluctant to discuss sexuality at all in their care settings (Gutheil & Gabbard, 1998; Quinn et al., 2011). This moral silence negatively impacts the prevention of boundary violations as well as the organization’s performance. In healthcare, it ultimately has a negative effect on the patient’s quality of life (Kröger et al., 2022).

In response to these less effective retributive organizational responses—focusing on individual punishment or compliance—some authors have argued in favor of a restorative approach. This approach aims to achieve a culture of dialogue, fairness, forgiveness, and learning from (potential) misbehavior, also referred to as a ‘just culture’ (Dekker, 2012; Fehr & Gelfand, 2012; Hollnagel, 2018; Wu, 2000). In this approach, the focus shifts from individual behavior to team level interactions, and from a backward to a forward looking attitude. However, to date, these ideas have been primarily conceptual in nature (e.g. Cullen, 2022; Dekker & Breakey, 2016; Verhezen, 2010). They do not address the impact of both approaches on teams, and the interplay between them. Our study addresses these issues. Our research question is: how does the interplay between sexual boundary violations, retributive and restorative organizational responses affect teams?

To answer this question, we draw on an in-depth case study in a large organization providing out-patient mental healthcare. Several teams in this organization reported sexual boundary violations by health care professionals. Our analysis focuses on the team level experiences with two cases of male professionals engaging in long-term sexual relations with their patient(s), and the organizational responses to these sexual boundary violations. Using a qualitative approach, we find that the violations and the retributive response trigger emotional distress, control, and distrust in these teams, thus inhibiting learning from these violations. Additionally, we see that complementing this with a restorative approach acknowledges the team’s distress, allows them to reflect on the impact of the violations and the retributive response, and heal relationships within teams. This, in turn, may open up the possibility of learning from these events.

Our main contribution involves a model that explains the impact of sexual boundary violations and the retributive responses, drawing on blaming as a mechanism. The model depicts the interplay between retributive and restorative responses that draw on dialogue as a mechanism. By focusing on the team level, this model extends prior research that concentrates on individual actions and outcomes with regard to violations. By combining retributive and restorative organizational responses in one model, we extend the literature on restorative organizational responses to boundary violations which is still at an early development stage.

Theoretical Background

Boundaries between people are key to defining their interrelationships. Particularly in relationships where there is power asymmetry—e.g. supervisor-subordinate, therapist-patient, professor-student—boundaries help to protect professional integrity (Celenza, 2011; Hancock et al., 2015; Nielsen, 2001). Boundary violations, employee (inter)actions that harm others or can be seen as morally objectionable (Greve et al., 2010), have received considerable attention in organization and management studies (e.g. Cline et al., 2018; Ermann & Lundman, 1978; Vaughan, 1999). Sexual boundary violations constitute a more specific form of this harmful organizational behavior, and there are many taboos that prevent employees from discussing such incidents (Celenza, 2011; Kröger et al., 2022). This is problematic as discussing boundary issues could potentially avert future violations (Alpert & Steinberg, 2017).

To better understand how organizations can respond to sexual boundary violations, we now turn to the literature which describes and critically discusses the standard, retributive, organizational responses to boundary violations. We then look into the literature that calls for an alternative, restorative way to respond.

Retributive Organizational Responses

Organizational responses to boundary violations predominantly focus on the retribution of the individual professional (the ‘perpetrator’). These responses involve elements of “seeking ‘payback’ or revenge, and giving offenders their ‘just desserts’” (Goodstein & Butterfield, 2010, p. 457). Violations often result in disciplinary measures for the professional. Retributive responses include, but are not limited to, practice limitations, suspension or license revocation (d’Oronzio, 2015; Surgenor et al., 2019), or mandatory participation in educational and/or treatment programs (Brooks et al., 2012; Spickard et al., 2002). Additionally, in order to avoid future boundary violations, retributive organizational responses frequently include establishing (policy) measures to define and secure a professional work environment (Epstein, 1994; Norris et al., 2003; Rawwas et al., 1994). The assumption behind this approach is that powerful actors can impose ethical values on employees, presuming they will act accordingly, via instruments such as codes of ethics or oaths like the Hippocratic Oath (Weaver et al., 1999).

Unfortunately, these retributive attempts to enforce ethical behavior via codes of ethics, oaths, or other policy measures fall short of expectations (e.g. Weaver et al., 1999; Weaver and Trevinõ, 2001), and potential perpetrators may not react to these retributive responses (Pope, 1990). Additionally, retributive responses to sexual boundary violations may give rise to fear, and in turn, induce moral silence (Verhezen, 2010). That is, (health)care and service professionals’ reluctance to discuss sexuality in their care setting. Such reluctance partly stems from the fear that discussions could lead to allegations of sexual boundary violations (Gutheil & Gabbard, 1998; Quinn et al., 2011). This moral silence is problematic, because ‘high quality’ (health)care and services may involve fostering an intimate bond between the service provider and the recipient, all the while maintaining appropriate (bodily boundaries and) professional distance (Hancock et al., 2015; Nielsen, 2001). This is, for example, the case where long-term and intimate treatment is common (e.g. mental healthcare or disability care). In such settings, sexuality and intimacy are regarded as aspects of a patient’s quality of life and are therefore part of their care (Kröger et al., 2022).

Given these problems with retributive responses, in recent years, scholars have shown growing interest in the response to (sexual) boundary violations, emphasizing restoration rather than retribution (e.g. Goodstein & Aquino, 2010; Schormair & Gerlach, 2020).

Restorative Organizational Responses

Restorative responses to wrongdoing have been discussed in the criminal justice literature as an alternative to retributive responses (i.e. punishment) (Wenzel et al., 2008). Restorative organizational responses are distinctive in their central focus on attempts to heal damaged relationships between victims, offenders, and other actors (e.g. teams, the organization, other stakeholders) (Dekker & Breakey, 2016; Goodstein & Aquino, 2010), as opposed to violations of laws or codes of ethics (Goodstein & Butterfield, 2010). Retributive responses tend to be ‘backward looking,’ focusing on an offender’s past actions (Trevinõ, 1992). In contrast, restorative responses to boundary violations are ‘forward looking,’ since they focus on healing relationships, and discussing implications for the future (e.g. Cullen, 2022; Goodstein & Butterfield, 2010).

Advocates of restorative responses argue that retributive approaches inhibit organizational learning by simply ‘blaming’ transgressors (cf. Schilling & Kluge, 2009; Vince & Saleem, 2004), and considering boundary violations mainly as an indication of individual professional incapacity or negligence. In turn, employees are reluctant to discuss issues or failures, if this could lead to disciplinary sanctions, or result in being blamed or ridiculed for mistakes (Edmondson, 1999). Opening up through dialogue, and being willing and able to share concerns are considered to be important aspects of a restorative organizational response (e.g. Dekker & Breakey, 2016; Schormair & Gerlach, 2020).

Three limitations can be identified in the recent literature on restorative organizational responses to boundary violations. First, although these responses are seen as a relatively new and important area for organizational ethics (e.g. Goodstein & Butterfield, 2010), many of these studies remain abstract in nature, developing constructs such as ‘moral recovery’ (Cullen, 2022), ‘moral repair’ (Vives-Gabriel et al., 2022), or ‘forgiveness’ (Fehr & Gelfand, 2012), without focusing on concrete experiences in practice. Second, recent studies apparently focus on restoring relations with external stakeholders rather than restoring relations within the organization. For instance, scholars theorize how organizations involved in human rights violations can restore relations with communities outside their organization (e.g. Gillespie et al., 2014; Greeley et al., 2020; Schormair & Gerlach, 2020). Third, the literature generally looks at the role of individuals in restorative responses. For instance, some studies focus on ethical ‘restorative’ leadership (Cullen, 2022; Neale et al., 2020), or perpetrators’ self-repair (Butterfield et al., 2021). This implies that existing literature does not study the impact that sexual boundary violations and the retributive and restorative organizational responses to these violations have on teams (e.g. Dimen, 2016; Gabbard, 2016), and falls short in enabling organizations and teams to recover from these incidents, and prevent future harm (e.g. Alpert & Steinberg, 2017; see also Alvesson & Spicer, 2012; Morrison & Milliken, 2000).

Therefore, in order to complement existing approaches, this study uses an empirical approach, investigating concrete experiences in practice, and focusing on relations within teams.

Method

This paper is based on an in-depth case study of a healthcare organization (Yin, 2003). A qualitative research approach helps us understand how sexual boundary violations are experienced in a given context, and how organizational responses impact teams’ efforts to deal with these incidents.

Case Description

The research setting in this case study is HealthCo (a pseudonym), a large out-patient organization providing mental health care. Two cases of male professionals engaging in long-term sexual relations with their patient(s) had been revealed at this organization. HealthCo’s management reported the incidents to the authorities, both men were suspended, and the legal system initiated a process of investigation, detection, and prosecution of criminal offenses. At the time of this study, the men were no longer working at HealthCo. For reasons of confidentiality, we do not include specific details about the teams or individual team members. After two years, HealthCo’s management took the initiative to organize meetings with the teams involved in the process. These initiatives were partly triggered by a request from two former patients, both victims of these boundary violations. The victims had requested a meeting with the team of professionals who were the direct colleagues of their perpetrators. The patients’ request coincided with and stimulated the management’s aim to prevent future sexual boundary violations occurring within HealthCo. In order to develop a violation prevention policy, HealthCo’s management proposed holding a ‘fishbowl session.’ During this session, the two victims and the remaining team members would discuss the incident and its implications for preventing future sexual boundary violations; the managers and the first author would sit in the same room and observe without interrupting. However, the team members objected to both the presence of outsiders (HealthCo managers and the researcher), and this approach’s primary focus on developing a prevention policy.

The team members argued that they first needed to take time to share experiences and look back on events. HealthCo’s management responded to these requests by arranging a series of team dialogues. The dialogues were led by two facilitators specialized in the Socratic dialogue method (Kessels et al., 2009). During these dialogues, team members’ questions, experiences, and values were examined without immediately focusing on solutions or prevention policies. Each session was aimed at allowing team members to share experiences with sexuality in the organization, and draw lessons from these experiences for the future. Only the two former patients and team members were involved in the first session. The following sessions were held with two separate teams, without patients or the management team present. All the participants agreed to the researcher attending the sessions without the patients.

Data Collection

We draw on key actors’ detailed narratives, obtained from a total of 20 semi-structured inter views (I1-20) research observations during two dialogue sessions (D 1–2), and a written summary of the first dialogue session. The perpetrators were not included as participants as they were no longer working at HealthCo.

We conducted semi-structured interviews with the two victims (I19 and I20) and ten healthcare professionals (I1-10) who were part of the team at the time of the sexual boundary violations. A summary of the first dialogue session with these team members, written by the facilitator, is included in the analysis. The first author made research observations during the next two dialogue sessions with two different teams. Six additional semi-structured interviews (three participants from each dialogue session) were conducted (I11-16) as well as two semi-structured interviews with HealthCo management (I17 and I18). In the semi-structured interviews we explored the topics with the informants. First, we evaluated the dialogue session that had just taken place (e.g. How did you experience it? What do you consider to be key moments in the dialogue? Why? What surprised you, what did you struggle with? What do you conclude from this?). Next, we addressed the informant’s perceptions of the boundary violations and organizational responses. This evaluation aimed to chronologically reconstruct the chain of events and (informant) perceptions since or even before the boundary violations occurred (e.g. Could you take me back to how this started for you, what did you see or hear? How did this impact you and the team? What happened next?). The findings from the sessions and interviews were presented and discussed at a final meeting attended by management, the two team leaders, the facilitators of the dialogue sessions, and the researcher. This resulted in additional data which served to triangulate earlier qualitative data.

Data Analysis

In line with Gioia et al. (2013), we applied a systematic inductive approach to concept development. This approach helped us capture our participants’ experiences and develop adequate concepts for theorizing about those experiences: it includes both first-order analysis (using respondent-centric terms and codes) and second-order analysis (using researcher-centric concepts, themes, and dimensions) (Gioia et al., 2013). Two researchers independently coded four interview transcripts inductively. Initially, the analysis focused on recognizing and mapping patterns in the participants’ experiences. A collaborative discussion followed the open coding, resulting in a tentative first-order coding scheme. The remaining transcripts were coded independently and discussed critically. The first-order coding scheme was further specified in two collaborative sessions, and we began seeking similarities and differences in the numerous categories. We then labeled the categories and defined the themes.

We reflected on emergent data, themes, concepts, and the literature on restorative organizational responses to see whether our findings had any precedent (Gioia et al., 2013). The second-order analysis work by Dekker (2012, 2013) turned out to be relevant. In particular, our second-order themes seemed to resemble concepts of second and third victimhood, focusing on the negative consequences for the perpetrator and other stakeholders, and how they might be countered by resilience approaches (see Wu, 2000; Dekker, 2013). We integrated and reflected on these theoretical concepts to develop a theoretical understanding of our findings. The iterative coding procedures and analyses resulted in our data structure, presented in Fig. 1.

Fig. 1
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Examples of quotes and coding scheme

Full size image

Nonetheless, the data structure presents a static picture of what is a dynamic phenomenon, failing to capture the connection between second-order themes and aggregate dimensions (Gioia et al., 2013). In contrast, the model we present in the Discussion section does capture the dynamic nature of employees’ and organizational responses to boundary violations.

Declarations

The participants were informed about the research project’s objectives and confidentiality, and that the findings would be reported in a scientific article. This information was provided again at the start of every interview and dialogue session. All the participants gave their oral informed consent. The case study was part of a larger study on ‘just culture’ in healthcare, for which the Erasmus Medical Center ethical committee (MEC-2018-054) granted ethical approval.

Findings

Our findings show how retributive responses to sexual boundary violations impact teams, and what hinders and enables these teams to restore their dynamics and potentially avert future violations. First, we show that the (retributive organizational responses to) sexual boundary violations triggered the mechanisms blaming (Schilling & Kluge, 2009; Vince & Saleem, 2004), and self-blame. These resulted in a build-up of emotional distress over a two-year period within the healthcare teams that the transgressors were working in. Consequently, the team members reacted by starting to control themselves and each other, labeling team members as suspects, and further increasing control. Second, our findings suggest that a restorative response drawing on dialogue (Dekker & Breakey, 2016; Schormair & Gerlach, 2020) can counter the unintended effects of retributive responses. Acknowledging the emotional distress in dialogue sessions alleviated the tension within teams, which in turn triggered healing team dynamics. This opened up space to learn from the violations. In the following two subsections, we look at the impact of (the retributive responses to) sexual boundary violations. The third and fourth subsections explore these impacts and the topics team members discussed for designing a restorative organizational response.

Retributive Dynamics: Blaming and Self-Blame Cause Emotional Distress

Both the sexual boundary violations as well as the subsequent retributive responses had an emotional impact on teams of healthcare professionals in the organization. Our findings distinguish four interrelated outcomes of blaming and self-blame that together explain why the teams experienced emotional distress: a fear of raising questions, lack of transparency, negative responses to expressing emotions, and loyalty conflicts with patients and colleagues.

Team members were shocked by the seriousness of the violations and the harm done to the patients. Additionally, they experienced strong feelings of disbelief as the violations had taken place almost right before their very eyes, regularly in office spaces next to their own offices, and they started blaming themselves. Several peer support sessions were held with team members right after the incidents to discuss the violations, yet feelings of disbelief were still very much present two years later. A team manager explains the impact of the violations:

What I found really shocking in this process, and what those patients said yesterday shocked them too, is that the employees, well, those involved in these incidents, they also burst into tears in these sessions. They’re at the very start, or halfway through, at the very least not ready yet [to admit], ‘Well, guys, this was my part [in what happened].’ And if after two years you still... if you’re still so sensitive, it means you haven’t found the space [to deal with it] throughout these two years. You haven’t talked about it with others for two whole years. (Manager I17)

Not only did the boundary violations have a large emotional impact on team members, it appears the retributive organizational response to the violations fell short in dealing with these complex emotions.

Fear of Raising Questions

In hindsight, participants acknowledged that they had noticed signs in the past suggesting that things may not have been quite right. But in the dialogue sessions and the interviews, participants said that they had refrained from asking critical questions when noticing ‘suspicious’ behavior or intuitively feeling there was something off about a colleague.

I’m not one of, well, often I am one of the critical voices, but not in this case, not with this colleague. I thought, yes, he gets a lot done and it’ll be fine. Naive [of me] in hindsight, but that’s what I thought.

(Team member I13)

Not raising questions [keeping quiet] was influenced by the way team members perceived the transgressors. According to this team member, the transgressor was someone who gets things done. The team member reflects how being young and insecure, and fearing how other colleagues might react to them raising suspicions, were reasons to not ask questions:

But then I was… it was more about me… and when you start out, you’re still young and insecure, so I thought: if I say something about the group now, colleagues might find it really strange. I thought: maybe it’s just a crazy idea of mine because social workers don’t do that, do they? (Team member I2)

In this case, the participant’s fear of the consequences resulted in them doubting their own observations and trying to rationalize not acting on these observations. In the dialogue sessions, team members expressed their fear of raising questions in the presence of the victims. One of the victims shared her disbelief:

Everyone [the team of healthcare professionals] was in awe or something of his [the perpetrator] ways of working…so much that they didn't dare to confront him. If you have such a position, and are so well educated and so...well, you know, you do such important work with vulnerable people and your reason for not asking questions is “well, I didn't dare”… I found it upsetting, and I thought yes, but I have put my whole life in your [the healthcare professional’s] hands. (Victim I19)

Lack of Transparency in Retributive Response

Following the allegations of violations, and after one of the alleged perpetrators was suspended, HealthCo’s management tried to keep the incident low-key and did not communicate extensively about it. This was partly forced by external factors (i.e. a criminal case inhibited openness) but was also because of HealthCo’s aim to protect the suspect until the allegations were proven. A team member reflects on the effects of the retributive response:

So, we lived in a kind of twilight zone for a long time. During the year he was suspended, the organization was not allowed to say what was going on, that two lawsuits were taking place. I think not talking about it sort of put a lid on it, like a kind of cover-up. (Team member I7)

The non-communication around the case did result in a perception of a cover-up among staff. This increased distress and created a difficult situation for team managers who felt the need and had a personal preference for openly discussing it with one another. A team manager explains the unintended consequences of the retributive response:

We weren’t allowed to say much. We had to [follow] a kind of silence protocol, you can’t say a word. You know a lot, but you can’t go to anyone and you hear teams asking, ‘What kind of mess is this?!’ And they just get mad at you. But you can’t do a thing. It lasts a while and then he gets honorably dismissed. I thought it was really difficult. Yes. That you know lots but can’t say a word, I found that very tricky. (Manager I18)

The lack of transparency in the retributive response had an emotional impact on team members as well as team managers. The long duration of the retributive response apparently further fueled the emotional distress within teams.

Negative Responses to Expressing Emotions

Research observations during dialogue sessions (designing the restorative response) indicated that people responded to emotions with sympathy and concern. In contrast, team members revealed that while creating the retributive response, sharing emotions about the violations evoked reactions that aggravated emotional distress:

I cried for two days; I was really upset for a week. That surprised me too. I thought, oh dear, this is doing such a lot to me. Yes, it says something about the pressure of work, but also about how involved I was. It touched me deeply and still affects me... makes me cry. The worst thing was, my team manager said to me, ‘Gosh, you act like he raped her right in front of you.’ Well, that still bothers me [interviewee bursts into tears].

(Team member I2)

It appears that a lack of acknowledgement of emotional distress contributed to distrust and fostered harmful team dynamics, and as such created a barrier to understanding why it had such an impact and to learning from this incident.

Loyalty Conflicts


Team members experienced different types of loyalty conflicts regarding the retributive response. This was a healthcare team whose members trusted each other. Friendships had emerged over time, and most importantly, participants stated that the team norm was to stand together, to be able to trust and build on each other. They spoke of how long they had known and worked side by side with this colleague. One team member reflects:

The perpetrator was a colleague of mine, and a good one too. He was a mate of mine here in the department. I had a lot to do with him. I knew him… well, I thought I knew him well. I liked him a lot, had blind faith in him. I regularly passed patients on to him. (Team member I1)

After their colleague was suspended, team members did not know who to trust. Some remained loyal to their colleague, also because they doubted whether the reported boundary violations had actually happened and how serious these violations were.

I really struggled with ‘but what if it isn’t true?’ What, then, do you do with a colleague? How loyal are you? Should I blame myself for not ignoring organizational policy and just giving that man some support, or getting in touch? Who should I trust? Should I trust that man, or should I trust the organization? It was all about trust! (Team member I7)

Such doubts evoked conflicting feelings. Some participants struggled to abandon trust in their colleague. In a close-knit team, loyalty to one another was seen as paramount and led to a tendency to close ranks:

At some point, a team will really close ranks, when such things happen. (Team member I6).


Eventually, once all the details became public, these conflicts of loyalty—to their colleague or to the patient—added to the emotional distress:

People were far more loyal to the perpetrator, and that remained difficult, especially when the magnitude of what he’d done eventually became clear. People got stuck in a state of thinking: yikes, what does this mean for me? That for so long I’ve been protecting something that really is so serious. (Team member I14)

With the details and scope of the violations becoming increasingly clear, colleagues who had been loyal to the perpetrator now developed a sense of guilt because their loyalty had been unwarranted.

The professionals involved not only felt loyal to their colleagues but also to the organization, which influenced how they spoke about the incidents. Discussing these incidents openly might have resulted in reputation damage for the organization, something the healthcare professionals considered. Another conflict of loyalty was at stake: loyalty to the organization versus loyalty to patients.

It had to be kept a secret from patients and I found that hard. I thought: what if it happened to someone else and we didn’t know? I still think it means: ‘Don’t bother people with it because it’ll have to do...’ But, I personally think you should have told all the people working in care [HealthCo] while he was here. You should have sent them all a letter: This happened and if it also happened to you, report it. I think so. But that’s impossible. You mustn’t because you can’t wake sleeping dogs. That’s the image. (Team member I2)

Participants understood the fear of negative publicity for the organization’s image. On the other hand, openness might have supported other patients being treated by the alleged perpetrators, who could have been victims as well. Ultimately, the participants experienced a conflict of loyalties, which had an emotional impact on them: loyalty to their colleague whom they trusted; loyalty to patients to protect them from unsafe situations; and loyalty to the organization that employed them.

Retributive Dynamics: Emotional Distress Triggers Control, which Fuels Distrust

The incidents and the resulting emotional distress affected the professional collaboration and trust between team members. Specifically, male employees were regarded as ‘the usual suspects’—potential perpetrators—and employees felt the need to increase the control in teams.

Gendered Perception of the Perpetrator

In interviews and dialogue sessions, the participants indicated that potential perpetrators were referred to as ‘he’ a male employee rather than ‘she’ a female employee. They also acknowledged that they generally think of perpetrators as men, specifically one type of man:

We always speak of ‘him’ in terms of an image of a certain type of macho, narcissistic man...

(Dialogue session D1)

One participant stated that they would rather not hire candidates who fit this description. Male participants said that that they found themselves in a tough position, constantly on their guard and forced to defend their gender in the organization:

In our context, working with so many women, it’s hard for a man. All the little jokes: ‘I wouldn’t mind a spot of his therapy... just teasing.’ I just walk on. It’s inappropriate and I pick up on it at times. So many signals. As a man you can hardly do the right thing anymore. I’m on my guard, no physical contact, no putting your arm around someone.... (Dialogue session D2)

This participant indicates the difficulty he has working as a male healthcare professional in a setting with many female colleagues. He feels that as a man, it is almost impossible to do his work well, with all his professional behavior potentially susceptible to complaints. In the dialogue sessions, a female employee argued that if a patient was infatuated with her, she could use this in treatment, for example by using flirtatious interactions with the patient to support such desired outcomes as treatment compliance. A male employee countered that this would be indefensible behavior for him, fearing a possible accusation of violating boundaries. Besides feeling the need to defend themselves against female colleagues, male participants also feared that openly discussing sexual boundary violations would increase the number of false accusations by (female) patients and heighten the personal consequences of such accusations. Male therapists questioned to what extent they could do their job well if they constantly had to deal with distrust, indicating the interplay between distrust and distress within teams. A male therapist reflects:

I’m a man working with vulnerable women, but I want to be able to do my job normally. Without having to constantly open doors and constantly answer for what I do. That really weighs on my mind. I work with people with personality disorders who sometimes want to do things to avoid dwelling on themselves. Or I’ll have a complicated talk with someone, have to tell someone off, who, for all you know, is thinking: ‘I’m going to get my own back on you.’ People can get caught out to the max. You get immediate suspension. There’ll be an investigation. Where there’s smoke, there’s fire. That’s the usual story. (Team member I16)

This team member articulated the need to be able to do his job in a normal manner, without having to constantly account for all his actions. His response also reveals the fear of retribution from patients who, in this setting, often have personality disorders. Allegations of sexual boundary violations have grave consequences, they result in immediate (temporary) suspension, which may explain increased levels of distress within teams.

During the dialogue sessions, employees concluded that male employees are viewed with suspicion, especially if they act in a ‘masculine manner’ like a typical ‘alpha male’ or a bit ‘narcissistic’. These characteristics were regarded as disadvantageous and risky regarding potential boundary violations. It was acknowledged that female employees might equally be committing sexual boundary violations. Interestingly, women’s potential misconduct appears to be perceived differently, as a team member reflects on the hypothetical situation where a female therapist was accused of a sexual boundary violation:

It is hard to imagine, I then tend to think she was probably manipulated by a patient. (Team member I2).

This demonstrates the impact of gendered perceptions of men as the usual suspects in an organizational setting where intimacy and sexuality are particularly significant. That is, these gendered perceptions fuel distrust among team members, while at the same time increase distress in response to the retributive approach.

Increased Control

During the retributive phase after the incident, in response to feelings of distress and distrust, healthcare professionals increased control. They took several measures, including registering their own actions, and observing, monitoring, or inspecting each other. This mostly concerned professionals’ whereabouts (‘if they are not in their office, where are they and who are they with?’), but also led to a discussion on whether or not to record all meetings and conversations with patients:

Yes, I did have a conversation with a team member, who at some point had begun recording and saving it all. Then at some point I responded to that and said: that’s not permitted. You’re not allowed to keep recordings of patients who are no longer in care. But then the specialist in the team said: Hey, keep it because if you get another bad allegation later, you can play it. (Team member I14)

Several participants mentioned that they knew of male colleagues who regarded making and saving recordings of meetings with patients as a viable potential defense against false accusations of sexual boundary violations. It shows how patients’ allegations of violation, whether justified or not, might cause defensive behavior in healthcare professionals and contribute to their awareness that it could happen to them too.

In sum, our findings thus far show how the sexual boundary violations and the retributive dynamics triggers blaming and self-blame which harm teams. Next, we explore the secondary organizational response which aims to restore relationships, and to learn from what has happened.

Restorative Dynamics: Acknowledging a Team’s Distress Through Dialogue

Three groups of actors—victims, teams, and HealthCo’s management—felt the need to learn from the sexual boundary violations, and co-designed the restorative response (see the Method section for additional details). The main sources for this response were the dialogue sessions. This and the following subsections discuss the themes explored in these dialogues as well as how team members perceived the restorative response.

Sexual Boundary Violations as a Gradual Process

While some participants felt that their former colleague, who had violated sexual boundaries, was ‘pure evil’, others still perceived him as a competent colleague. Although they found his behavior unacceptable, they considered it had likely been formed in a gradual process that had not begun with the intention of violating sexual boundaries:

In the meeting on that evil deed, I said that I didn’t want to discuss it in those terms because I see it very differently. I hate what happened. But I’ve also seen him as a good colleague, and I find it important that we talk more about human things like infatuation and stuff like that. (Team member I14)

Other colleagues shared their amazement that this particular professional turned out to be the transgressor. Some even went a step further, and were apparently open to the idea that victimhood may not be as black-and-white as it seems:

Everyone was scared to death at first. That it had happened, that it had happened to him [the perpetrator/ colleague], that he’d done it. And the extent to which it had happened. I felt that everyone was very shocked by that. (Team member I3)

Recognizing Each Other’s Vulnerability

In the interviews, team members shared that they had encountered situations in the past when they themselves had been vulnerable to developing feelings for patients. A team member explains, also articulating that this is a team issue, not just an individual struggle:

You can lose yourself in a patient. That’s only human. That’s the point…that it’s safe enough to be able to talk about having feelings like that. What you do with those feelings. Yes, and what you need to do together to solve things in a good way. That’s what you’re looking for actually. As a team too. Because otherwise it’s so lonely, being the only one dealing with it. (Team member I12)

Team members agreed that it is important and effective to discuss sexuality and intimacy, to find and maintain the right balance between proximity to and distance from patients, to support each other and prevent boundary violations or misconduct from happening. However, they recognized that sharing these sensitive issues makes them vulnerable. As they are all vulnerable, a team member argued, they are dependent on each other (i.e. vulnerability appears to demand reciprocity) to remain aware and alert regarding the slippery slope towards violations:

It works, talking about it together. We can help and support each other. We’re all vulnerable. Together we can ensure that we don’t slip back. (Dialogue session D1)

Restorative Dynamics: Healing the Negative Impact on Team Dynamics and Opening up a Learning Space

This subsection explores how creating the restorative response facilitated healing team members’ distress, and that over time, this response served to open up a learning space.

Overcoming Moral Silence

Respondents acknowledged that it is important to be able to discuss sexuality and spot the warning signs of potential violations at an early stage. At the same time, in the individual interviews, several participants stated that ‘real’ personal experiences, such as infatuations with patients, are difficult, if not impossible, to discuss in their own teams. A team member elaborates on this issue:

…that’s a pity, I think. But I don’t know how to talk about it properly. Because as I said, I don’t think it makes much sense to talk about it in a team meeting. Like asking, ‘So, do you ever have erotic feelings for a patient?’ I do think it’s our job as an organization to create opportunities to discuss it. If it happens to someone, then it’s more likely that they will talk to someone about it. (Team member I5)

Team members feel there is a managerial responsibility to facilitate opportunities that make it easier for them to talk about such situations. However, team members also find it difficult to articulate what might help create such opportunities, particularly in team settings. Some participants said they did discuss cases of personal infatuation, but only with those colleagues whom they explicitly trusted to give and receive honest responses without passing judgment.

The point is that you dare to be very close to someone. It’s not just about falling in love or the erotic or something. It’s also about… well, for example, if I made a [loving] comment to someone who is feeling suicidal and my colleague asked: Was that necessary? Well, naturally, being in love is a lot more personal.

(Team member I3)

During the dialogues, team members also reflected on discussing sexuality in the here and now (rather than referring to the past) with their patients, to define what is considered appropriate behavior in the treatment relationship and for setting personal boundaries.

Patients are involved, but we don’t actually discuss sexuality in the here and now. That’s kind of crazy, actually. How do patients know what good manners are in [professional] communication? How do we support them in this? We should talk about it more. (Dialogue session D2)

Team members stressed that being able to discuss sexuality openly in teams demands a skilled facilitator. One of them explains:

I find him [the facilitator] a true artist. I really think so. I noticed it in that preliminary interview because it excited me too. I think he acts with such integrity. What he can do – oh, it happened in that meeting too! Then he said, ‘Wait a minute, this is an aspect of experience. It’s not about true or false, it’s someone’s experience.’ That’s how he makes sure that all kinds of experience are possible. He gives you the space to say what you think. Yes, that gives me lots of confidence. I saw it in the preliminary interview, and it gave me confidence the moment I joined in the conversation. (Team member I11)

What supported participants to discuss sexuality was a facilitator who actively guided the process, invited them to engage in dialogue and reflection, and encouraged them to be vulnerable and honest about themselves. Whenever there was a collision of perspectives and values, the facilitator aimed to validate each view without passing judgment, thus ensuring an open, respectful atmosphere.

Restoring Harmony

Participants experienced the dialogue sessions as a contribution to recovering from emotional distress, restoring trust, and facilitating learning from these incidents in the organization to prevent sexual boundary violations in future. Our findings show that these sessions contributed to (a) restoring harmony, and (b) supporting each other to prevent future incidents.

The dialogue sessions seem to have supported and/or initiated the process of recovering from emotional distress built up during the two years of creating the retributive response:

I can’t quite explain it, but I noticed that I was blaming it all on myself, but that’s calmed down a bit.

(Team member I11)

Participants experienced the dialogue sessions as approachable. Experiences were discussed and examined openly, without an immediate focus on finding solutions or prevention policies.

I just thought the atmosphere was open, and yes, I don’t know if friendly is the right word, but at least it was open to us saying things the way they are. (Team member I10)

This allowed the participating team members to share their personal experiences, feelings, and emotions, and reflect on these together.

Opening up a Learning Space

There was a growing awareness during the dialogue sessions that sexuality or intimacy are never really discussed within the team. Participating team members agreed that there should be more space to discuss such issues like finding the right balance between distance and closeness to patients and colleagues. A team member reflects on (the complexity of) discussing professional boundaries more openly:

I’ve been in a conversation with two men and a female patient when I saw the man, my colleague that is, not looking the woman in the eye but, let’s say, lower down. Then I felt vicariously ashamed. Later, I should’ve told him off. I didn’t, but I should’ve said, ‘Boy, shame on you. You should just look at her face.’ Yes, it’s hard, especially if you’re not used to it. (Team member I5)

This participant is articulating that, again, it is hard to speak up about inappropriate behavior, in this case gazing at a female patient’s chest. At the same time, it also shows an awareness of the importance of discussing it and trying to find ways to achieve this in practice. The fostered awareness of the importance of discussing sexuality and intimacy within the team gave rise to several initiatives to put these topics on the organization’s agenda. The proposals ranged from including matters of sexuality and intimacy in the training program for all new employees, to discussing these topics during moments of reflective practice, including moral case deliberations and ‘inter-vision’ sessions (where peers discuss complex cases, interrogate each other, and collect feedback), and to organize these dialogue sessions with other teams in the organization.

As far as I am concerned, you should actually have this kind of conversation once a year, so to speak, to try to prevent incidents of this type from occurring more often, instead of looking back [and wondering] what did we miss? (Dialogue session D2)

The dialogue sessions contributed to an open dialogue on sensitive subjects such as sexuality, and moreover to achieving awareness of the value of putting sexuality on the organization’s agenda.

Discussion

The purpose of this study is to explore how (retributive and restorative responses to) sexual boundary violations impact teams.

Our findings are summarized in a model depicting how the interplay between sexual boundary violations, retributive and restorative organizational responses affects teams, as shown in Fig. 2. The left column highlights that blaming perpetrators—an underlying mechanism of retributive dynamics, derived from the literature (Schilling & Kluge, 2009; Vince & Saleem, 2004)—and a team’s self-blame, derived from our findings, profoundly impact the teams in which perpetrators work. More specifically, the interplay between teams’ emotional distress, control, and distrust hinders a team’s effectiveness. The right column shows that an organizational response triggering restorative dynamics may enable teams to reflect on the retributive response and learn from it. Restorative dynamics, drawing on dialogue as an underlying mechanism (Dekker & Breakey, 2016; Schormair & Gerlach, 2020), lead to a more nuanced view of team members. That is to say, by acknowledging a team’s distress, team members come to see the transgressor as most likely not a predator, but as a person who has gradually slipped into behavior resulting in boundary violations. Team members may come to realize that they are all vulnerable to these transgressions. In turn, this triggers healing processes, whereby team members eventually realize that it could well be a team’s responsibility to overcome moral silence about complex issues in order to prevent future harm.

Fig. 2
figure 2

A model depicting how the interplay between sexual boundary violations, retributive, and restorative organizational responses affects teams

Full size image

Overall, the model outlined in Fig. 2 connects the literature on retributive and restorative responses to sexual boundary violations in healthcare. It explains how to combine the retributive response—based on blaming, with a restorative one—drawing on dialogue, thus enabling teams to acknowledge the impact of the violations and the retributive response they trigger. This reflection opens up the possibility to learn from these events and potentially avert future violations.

The remainder of this section details the theoretical implications from Fig. 2.

Theoretical Implications

First, it is important to look beyond an individual’s actions and the outcomes of violations (Butterfield et al., 2021; Cline et al., 2018; Cullen, 2022; Neale et al., 2020). This can prevent ignoring the consequences of violations on teams, a factor that has been previously acknowledged (Dimen, 2016), but not yet studied in great detail (e.g. Gabbard, 2016; Raver and Gelfland, 2005). Prior research on sexual harassment within teams (i.e. between team members) has demonstrated the impact of these violations on team performance and the struggles between team members (Raver and Gelfland, 2005). This study extends these insights by showing that sexual boundary violations resulting from team members’ interactions with people outside the team (i.e. patients) negatively impact team performance (e.g. the quality of healthcare provided), relations between team members, and inhibits learning from violations. Yet, and perhaps more importantly, besides identifying the undesirable consequences of these violations on teams, this study sheds light on how teams can reflect on the violations and the retributive response and open up avenues for learning. This is particularly important as teams provide an obvious setting for detecting and discussing peers’ troubling behavior (Gromet & Okimoto, 2014; see also Bain et al., 2021; Satterstrom et al., 2021). It is therefore also an obvious setting for learning how to prevent future violations.

Second, our study contributes to the literature on restorative responses to boundary violations which is “still very much at an early stage of development” (Goodstein et al., 2014, p. 315). By providing insights on team members’ experiences, our study shows that a restorative approach can lead to acknowledging distress and recovering from it through dialogue. Moreover, our study provides input for a further conversation on how to combine retributive and restorative responses to sexual boundary violations. Our findings acknowledge the negative impact of retributive responses (see Heraghty et al., 2020; Dekker, 2012; Leape, 1994), but for legal and moral reasons they cannot be fully prevented. There is very little empirical research on how organizations can combine retributive and restorative responses (e.g. Schormair & Gerlach, 2020). Our study shows that dialogue can be a powerful tool to achieve this. Prior work has studied how the conventional justice system could institutionalize ‘restorative approaches’ to regulations (Bertels et al., 2014; Braithwaite, 2002). We are not aware of prior work that focuses on integrating retributive and restorative approaches to acknowledge distress within teams, or on developing practices to learn from these events, opening up the possibility to prevent future harm.

Prior studies, by virtue of their conceptual focus (Dekker & Breakey, 2016; Goodstein et al., 2014; Verhezen, 2010), or individual focus for example on leaders (Cullen, 2022; Neale et al., 2020), and perpetrators (Butterfield et al., 2021) tend to paint a rather static image of the occurrence and impact of boundary violations (Gromet & Okimoto, 2014). The model based on our findings, on the other hand, creates a deep understanding of the dynamic, interconnected, and relational nature of the occurrence and impact of (retributive and restorative responses to) boundary violations. This dynamic view is particularly important because it highlights the gradual character of these violations (Aravind et al., 2012; Galletly, 2004; Welsh et al., 2015). From the perspective of the perpetrators’ team members, our findings suggest that transgressors being seen as ‘predator doctors’ is unlikely. Rather, this study’s focus on team dynamics allows team members to reflect critically on their role in (not) signaling or acting on suspicions at an early stage. This study’s dialogical approach and focus on relational dynamics, in responding to calls to study and discuss boundaries and their violation, could thus contribute to averting future violations.

Limitations and Future Work

Our study draws on an in-depth case study of one healthcare organization. This may limit the generalizability of the main findings. Our findings can be readily generalized to other (teams in) large out-patient organizations providing mental health care where similar sexual boundary violations have occurred, yet, perhaps to a lesser extent in other organizations, and with less extreme cases. Future work could explore to what extent these findings also apply to different kinds of healthcare settings such as hospitals, nursing homes, and non-healthcare organizations.

Additionally, future work could explore to what extent the extremeness of our case study influences the dynamics in our findings and in the model, since the violations in this case study were so extreme that legal action had to be taken and a retributive response was required. As sexual boundary violations are a slippery slope, sexual and other boundary violations may seem or start out as minor violations, yet they can ultimately lead to serious ones (Aravind et al., 2012; Galletly, 2004; Welsh et al., 2015). Therefore, studying less extreme cases of violations appears to be a particularly important avenue to explore, as the main goal of studying sexual and other boundary violations is to prevent greater future harm, i.e. more extreme violations (e.g. Alpert & Steinberg, 2017). Future research may also want to investigate what role the time aspect plays in the dynamics between the retributive and restorative response. In our case study, lengthy criminal investigations prevented starting a restorative response shortly after the boundary violations had taken place. This may have affected the emotional distress in teams and the further interplay between retributive and restorative responses.

Furthermore, whereas our findings show that combining retributive and restorative approaches serves to open up a learning space, we cannot be sure about how this affects the prevention of future harm. Longitudinal studies, e.g. process studies, or action (design) research, could, besides empowering teams to develop dialogical capabilities to deal with transgressions (Van Baarle et al., 2022), shed more light on how these actions and capabilities affect preventing future harm.

Concluding Remarks

Our findings explain how organizational responses to sexual boundary violations impact healthcare teams. They show that retributive responses inhibit teams learning from these violations. On the other hand, by combining these approaches with restorative responses, teams are able to acknowledge these impactful events and heal their team dynamics. This may result in an environment that is safe enough for actors to discuss moral dilemmas regarding the professional intimacy/distance balance; and open up a space where teams can learn to recognize signals, discuss, and address violations at an early stage.