¹RN, Resident in Obstetrics, Centro Universitário Franciscano, Brasil.email: brunadedavid.rocha@gmail.com.

²RN, PhD. Professor, UFSM, Brasil. email: mclanderdahl@gmail.com.

³RN, PhD candidate. UFSM, Brasil. email: lferreiracortes@gmail.com.

⁴RN, PhD. Professor, Universidade Federal do Rio Grande do Sul, Brasil. email: lebvieira@hotmail.com.

⁵RN, PhD. Professor, UFSM, Brasil. email: stelamaris_padoin@hotmail.com.

Receipt date: January 20, 2015. Approval date: April 30, 2015.

Article linked to research: "Violencia contra las mujeres en la perspectiva de estudiantes de enfermería".

Subventions: none.

Conflicts of interest: none.

How to cite this article: Rocha BD, Landerdahl MC, Cortes LF, Vieira LT, Padoin SMM. Violence against women: perceptions of nursing students' about the focus on the formation. Invest Educ Enferm. 2015; 33(2): 260-268.

DOI: 110.17533/udea.iee.v33n2a08

ABSTRACT

Key words: women's health; violence against women; credentialing; nursing; education nursing.

RESUMEN

Objetivo. Conocer la percepción de los estudiantes de enfermería de una universidad pública en el sur de Brasil, sobre la inclusión en el currículum del tema de la violencia contra la mujer y con respecto al abordaje de la temática durante la formación. Metodología. Investigación cualitativa exploratoria descriptiva realizada con 18 alumnos de Enfermería. Para la toma de información se utilizó la técnica de entrevista semiestructurada y los datos se sometieron al análisis temático de contenido. Resultados. Para los alumnos la temática integra el contenido curricular de manera puntual, aunque con carga horaria reducida. Se presentaron dificultades en la identificación de la violencia y en las acciones que serán desarrolladas. Los participantes sugieren que la temática debería ser trabajada desde el inicio del programa, permeando el aprendizaje en Salud Colectiva. Conclusión. El estudio muestra la necesidad de incluir la violencia como tema transversal a los currículos de los cursos de Graduación en Enfermería y Salud.

Palabras clave: salud de la mujer; violencia contra la mujer; habilitación profesional; enfermería; educación en enfermería.

RESUMO

Objetivo. Conhecer a percepção dos estudantes de enfermagem de uma universidade pública no sul do Brasil, sobre a inclusão no currículo do tema da violência contra a mulher e do com respeito à abordagem da temática durante a formação. Metodologia. Investigação qualitativa exploratória descritiva realizada com 18 alunos de Enfermagem de uma universidade pública no sul do Brasil. Para a tomada de informação se utilizou a técnica de entrevista semiestruturada e dados foram submetidos à análise temática de conteúdo. Resultados. Para os alunos a temática integra o conteúdo curricular de maneira pontual, ainda que e com carga horária reduzida. Apontou-se dificuldades na identificação da violência e nas ações que serão desenvolvidas. Os participantes sugerem que a temática deveria ser trabalhada desde o início da graduação, permeando a aprendizagem em Saúde Coletiva. Conclusão. O estudo mostra a necessidade de incluir a violência como tema transversal aos currículos dos cursos de Graduação em Enfermagem e Saúde.

Palavras chave: saúde da mulher; violência contra a mulher; qualificação profissional; enfermagem; educação em enfermagem.

Violence against women (VAW) is considered a public health problem for influence the context of life of people living or experiencing this situation, generating impact on the social, psychological and work conditions and in the citizenship of the woman and her family. It became notoriety by being denounced by feminist movements worldwide, boosting debates and achievements in its confrontation. The Inter-American Convention for Punishment, Prevention and Eradication of Violence against Women - Convention of Belém do Pará/Brazil (1994), featuring the VAW, as any act or conduct based on gender, which causes death, damage or physical, sexual or psychological suffering to women, whether in the public or private space.¹ It is characterized by the attempt to regain power illegitimately, by authority imposed by physical force or fear, from one subject to the another.² In this study, we work with the gender category that means understanding the phenomenon of violence stems from the hierarchical relations established between men and women, which have a history/social/cultural character that marks and defines the body of each subject and its field of actuation.³ It is a broader understanding than that directed to causal factors and establishing demands, also, to the Health Area.

In 2004, the Brazilian government, sensitive to international conferences and conventions appeals, drew up the National Policy to Face Violence Against Women, which establishes guidelines for the prevention and intervention of the problem. Also determines that assistance to women either through a network of different sectors, including the health.⁴ Brazil occupies the 7th position worldwide, as one of the countries with the highest femicide rate, murders of women for reasons of gender. In 2011, were registered 73 633 care attendance related to violence in the country and 48 152 (65.4%) were women. The place of residence of these women was in most cases the scene of violent situations, having as their aggressors, the spouse or boyfriend, old or current.⁵

The VAW results in serious consequences for the physical and mental health of women. Cross-sectional study, in Colombia with 150 women with a history of violence, shows that depressive symptoms and chronic pain were presented in 74% and 42% of participants, respectivly.⁶ These demands reflect in greater demand for health services. However, many professionals find it difficult to identify the history of violence and work with women, restricting its activities to the physical signs and symptoms.^7,8 The Health Area has pioneered the field to identify situations of violence, ⁹ as health professionals, especially nurses, perform the initial care to women in situations of violence. However, we question the preparation of these, to act in care services since care practice is hampered by the limited understanding of the professionals on the subject, or even ignorance to identify situations in its various forms, which often rather make invisible the question in the health field.^8,10,11 For Nursing, often, the work is limited to support, without institutional commitment to identify situations of violence and realize the needed demands.⁹

This conduct is attributed to gaps in training, with regard to instrumentation for interpersonal relations, as well to integrality of care actions. It can be seen major concern of Health academics, in general, with the technical competence improvement, than competence for professional/patient relationship affected by violence.¹² Reiterates that still dominates the fragmentation of knowledge, in which disciplinary practices are guided, often, in biologicism and medicalization. Competences for the health work need to be based in the insertion into practice scenarios, which demonstrate the health needs of the community. Strategies are needed to transform the training process, the services and pedagogical practices, combining the health system and the training institutions, for an education with a critical and reflexive eye.¹³ Thus, we highlight the importance of the inclusion of this theme in the process of training Health professionals, especially in Nursing. It is believed that nurses need to have subsidies to act both in the identification of situations of violence, in the host, support and referral of demands. Also, with the importance of this theme in social relations and public health, justifies this research, since we believe that the results obtained can generate reflections in teaching in order to contribute to the inclusion of the theme in the curriculum of involved areas. Therefore, this study aimed to know the perception of nursing students from a public university in southern Brazil, on the inclusion of the theme violence against women in the curriculum and on thematic approach during graduation.

METHODOLOGY

This is a qualitative study, exploratory and descriptive, since this type of research work with the interactions between people, human interpretations as how they live, feel and think. Constituting not only the decoding of data, but in the understanding of the context in which it is inserted.¹⁴ The study setting was a Nursing Undergraduate Course at a public university located in Rio Grande do Sul, Brazil. The participants were 18 students enrolled in the course, which was the last year of training, 15 women and 3 men, whose ages ranged between 21 and 31 years old. To participate in the study, the following criteria elected up were: be enrolled in the last year and attending regularly theoretical and practical classes. We opted for the last year of training, since the theme was included in the curriculum in the previous period (sixth semester) through content in complementary discipline, Women's Health.

The research project was approved by the Research Ethics Committee of the institution under protocol CAEE 20696913.5.0000.5346. In order to ensure the confidentiality and anonymity of the participants was used in the speeches a code with the letter A, academic, followed by a number. The study followed the Resolution no. 466/12 of the National Health Council in Brazil, which addresses ethical issues in research involving human subjects. The academics were invited to participate of the research and, after understanding and agreement of the exhibition of ethical issues, signed the Informed Consent. The production of data occurred from September to October/2013 through semi-structured interviews performed in Health Sciences Center University. The interview questions were about the moment and way in which the theme was approached in the formation, the perception of academics about this approach, which were recorded in a digital audio recorder. The number of interviews followed the criterion of data saturation.¹⁵

Data were transcribed, in order to make the interpretation and thematic analysis proposed by Minayo.¹⁴ This procedure consisted of three stages: ordination, data classification and final analysis. Thus, floating reading of the interviews was analyzed, identified the main ideas on approaching the violence against women in the perception of academics; were selected significant excerpts from speeches and by reading and rereading, were developed the chromatics coding of the findings. Thematic categories were built, highlighting the convergence, divergence and similarities of participants' speech. The final analysis was to articulate the structured corpus to theoretical basis, in order to identify the underlying content to manifest, in an attempt to meet the aim. The following categories were detached: "punctual and limited focus of the theme" and "The difficulties to act as future nursing professional."

RESULTS

Punctual and limited focus of the theme

The approach of the VAW in nursing education, in view of the participants, it is important and needs to have a greater focus during the undergraduate course. The fact that this theme is studied only in a complementary discipline, in a timely manner, limits the further exploration of the topic. Argue and reinforce missing discussion moments on the theme throughout the undergraduate and not only in women's health discipline: [approach] is still very superficial, because it needs to be treated more seriously this theme [...] There are still weaknesses in it [...] [A9]; [...] Is a very current theme [...] should have more moments of discussion about it [A17]; [...] It is a subject that people do not know because it was a SDG [supplementary discipline graduation] was not a chair [discipline] [...] would have to have more and we should knew more resources, because I do not know enough [A18].

Report that VAW issues are not covered in the curriculum. Some specific interventions, such as class and approach to preventive campaign, were held, tied to teachers mobilized to work with the issue. Believe to be an issue that needs discussion moments, the unknowledge of how nurses can act in these situations. Suggest a higher workload. Also, point out that the issue needs maturity of academics, to relate theory to practice: [...] I think in the undergraduate people are not mature enough [...] They cannot relate theory with practice. These are serious questions that we need to have discernment [A9]; There is still plenty of time for those discussions that are important [...], many people have difficulty with this issue because they do not know how nurses can act on it [A13]; I think that is less than what we need really, I think everything that addresses women's health, especially the violence, does not occur in hours [A14]; During a week of activism of violence against women, a teacher, for her to identify with this theme, made this approach, but we do not have it in the curriculum. [...] [A15], would be important to greater workload [A18].

The participants expressed that the theme should be worked since the beginning of the course. Mainly because that, in the first semesters, is given the discipline of Public Health, in which the students have contact with his first practice: the basic health units (BHU) and the Family Health Strategy Units (FHSU). They also suggest that could be addressed in all semesters in a continuously way. Others argue this could be taken mainly in the seventh and eighth semesters, in which professional training approaches: In every semester, I think essential [...] in the seventh and the eighth [last year] should be strengthened many things [. ..] talk about gender-based violence, women's rights [...] resume that care line, those referrals, tertiary services, women's police station, primary care, reviewing all that flow now [...] [A8] ; I think there in the first [semester] because we already goes to public health [...] goes to family, and we know that many families who had had some pretty complicated stories [...]. If we could also work with adolescents on violence, because [...] is a cultural thing [A9]; [...] Perhaps this should be worked from the beginning, there when we go to the first time an FHSU [...] [A14].

The difficulties to act as future nursing professional

Participants reveal difficulties in identifying a woman in a violent situation that comes to health care. Also, they say that would not know how to act and make referrals, as future nursing professionals. Moreover, violence is mostly identified by physical injury, and is considered to most, subject to police report: It would be difficult to identify a woman who arrives in the health service, you look at her, you see that she's a purple arm, belly, something like that. It maybe you perceive that this is not only a bruise, you know? Realize that you have something, that has the violence behind it [...] That we would have to work more in the course [A4]; As a professional we're not really prepared to act, because at graduation we only have a semester, until I did not know how act in a correct way [A12]; Know how to work with the measures applicable to the situation, from counseling to referral to the police, if necessary [A16].

In contrast, externalizes the concern of academics to create bond with the woman and know the reality in which it operates, as well as talk about the situation and inform her that is her right to live without violence. In one of the speeches, it is noted that the man aggressor needs to be reminded in this context of violence, so he must have free support in health services: The first thing I seek to do [...] is to inform the person she need not go through it [...] she has to know that is suffering violence, do you understand? To get it to break free of that [A8]; [...] First you have to create a link, know the reality [...] we do not have to judge the man because I think the man that attacks, he also has problem, do you know? And often we forget it [...] [A10].

Some strategies of action are identified by participants, as the nursing consultation, group formation or conversation circles, trigger competent agencies such as the police woman station, make referrals to social workers and the multidisciplinary team: Has to try to trigger [...] I do not know what the agencies, but an agency of responsibility, type, that police woman station [...] make this woman be empowered so she understands that she does not have to live that way [A9]; [...] I think we cannot do the job alone, cannot be only by nursing, has to be the doctor [...] has to be the psychologist [...] a team has to try to help [A10]; What I did when I saw this case was try to schedule a nursing consultation so they could talk to this woman, guide, listen her [...]. I do women's groups related to this, a wheel, in this way we can talk about. [A17]

DISCUSSION

The results point to the need for violence against women to be addressed throughout the nursing undergraduate. In the speech of academics, their critics consist, mainly, of the late availability of the subject in the course curriculum - third year, as well as the offer in a complementary discipline during the graduation. The transversally proposes that the theme violence against women, is crafted of continuous and integrated way in the curriculum, interacting with knowledge from different fields of knowledge. That is, the subject must be present in all semesters and have relation with care practice allowing the learning from the relationship of reality experienced by academic and life issues of people.¹⁶

Students are positioned pointing that classes were important and helped in their learning. However, consider insufficient hours to discuss the complexity that encompasses the violence. Punctuate these issues mainly, because in the routine of health services, as future professionals, they will need theoretical support, which may benchmark actions aimed at comprehensive care to women in situations of violence. It is understood that the academy itself favors the fragmentation of learning, when it works only content within the limits of disciplines, decoupling theory and practice, which turns out not to encourage discussion and criticism of future professionals. Higher Education Institutions (HEIs), especially in the Field of Health, need to strive for training professionals acquire skills and abilities from the construction of knowledge, subsidized in teaching practices which aimed at completeness and interdisciplinarity.¹⁷ In this way, this demands point to overcome the academic training, biologicist and reductionist model, that does not consider the social determinants as important markers in the health and disease.

In order to enhance the transformation of this model, it is necessary to mobilize strategies associated with approaches from other areas of knowledge, such as Sociology and Law.⁴ Resulting in the health engagement with human rights, the restoration of ethics in interpersonal relationships, integrated treatment, and political commitments that include greater gender and social equity.^8,10,11 According to the National Curriculum Guidelines (NCG) for Undergraduate Courses in Nursing in Brazil, curriculum should contribute to the training of professionals with skills and abilities to work with critically approach in the Brazilian Unified Health System (UHS), taking into account the context of life and the population's needs, ensuring the completeness of their actions and humanized care of individuals, families and comunities.¹⁸ Therefore, the NCG already proposed that academics, as future professionals, are able to act on an expanded way being responsible for cultural, social and economic issues that may result in harm to physical and mental health, as is the case of violence against women.

VAW has been discussed only when studying women's health, in the sixth semester, contradicts the guidance of NCG as the academics perceive vulnerable situations such as violence, when performing the traineeship (practical classes) in primary care, in initials semesters. Future professionals need base their practice on the defense of human and social rights and aggregate actions that enable a care with a view to completeness. Therefore, it is necessary to combine what is recommended by public health policies, education policies and general and specific skills of nurses to intervene in social and health problems. This can be achieved through the training of teachers and professionals to contribute to an academic background based in the critics and reflection of these vulnerable situations.¹⁹ It is important to reinforce the role of primary care, when we think in actions related to the VAW, with the emphasis in promotion and health prevention⁸ as well as the possibility to bond with women and families through home visits, made possible by the FHSU and by the bigger women's access to this level of attention, mainly, by actions throughout the woman's life cycle and the link with the community, which leads to search for the primary health care service.¹¹

Another possibility of health professionals acting is during pregnancy and childbirth for women. Study shows that VAW often occurs simultaneously during pregnancy and is associated with adverse effects on the mental health of pregnant women, such as postpartum depression. We emphasize the potentiality of nurses, which are inserted at different levels of health care, to identify cases of violence also in pregnancy and childbirth cycle. As well as the detection of possible disorders resulting from this situation in the pre-natal and puerperium consultations.²⁰ Thus, home visits and the moments when the woman are searching the primary health care for routine consultations could also be used for this propose.⁷

Regarding the presence of the subject in the curriculum, study shows that health professionals recognize that they did not have classes about VAW during their professional formation, so consider that these cases should remain within the security and justice, not blaming the health area.²¹ It follows from the VAW theme should be addressed during the professional formation of nurses as and other health professionals, and also need to be enabled moments of continuing education in health services. This will be reflected in a better technical preparation of professionals in the health care of women in situations of violence, so that this grievance be identified in health services, strengthening the support network in the NHS.²²

In view of the participants, discuss the matter during graduation, even occasionally, allowed to give visibility to situations of violence in their daily lives, which reinforces the need for deepening the theme. After all, the theme is still not addressed satisfactorily and not fully included in the curriculum, by the fact that practical classes and internships, despite the new curriculum guidelines, mainly occur in the hospital scenario, to the detriment of the primary health care level. In the hospital scenario, the identification of violence and psychosocial approach are in the background, in relation to the biological demands of violence.¹⁹ There is a need for institutions to rethink how to approach these themes in academia, enabling practice spaces for students have contact with the reality of users and know how to identify and act in front of it,²³ through the bond, listening, guidance and multidisciplinary teamwork.⁴ One possibility to work the theme is the use of problemsolving methodology, based on new pedagogical trends that points to the need to form a critical-reflective professional able to be active in their own learning and to transform the social reality in which it is inserted.²⁴

The report of the scholars on the difficulties in identifying the violence and the conduct demonstrates a lack of protocols for the care of VAW. They emphasize that the formation still has many weaknesses, such as the need for thematic discussion moments, more hours and theoretical-practical classes. The results indicate, therefore, the need to strengthen not only the graduation, but also professionals of health services, which also contribute to the process of training of academics. For this to be made possible, it is important an intersectoral coordination, especially with forming agencies such as universities, in order to stimulate research and studies related to theme.¹⁰

Finals considerations. The study showed that having a space in the university to discussions about VAW promotes important reflections, allowing other looks and positions about these them. This new look to violence, already represents an advance as it seems to be encouraging the empowerment of future nurses, professionals that should be protagonists of the necessary changes in the health field in defense of women. It is necessary another studies in this line in order to stimulate reflections that reinforce the compromise of Nursing and Health to contribute in facing violence against women, a phenomenon so naturalized in mainstream culture. It is recommended, the transformation in the training process, mediated by the implementation of participative/active pedagogic methods, in addition to the instrumentalization of academics to act in facing VAW. It is indicated the problemsolving methodology as possibility of get the objects of studies from the perception of reality and, especially, the student protagonism. Therefore, can be extend the learning situations in primary health care, for example, where there is greater proximity to families, getting to know the contexts of greater social vulnerability which breeds violence. Following the challenge of rethinking the VAW as a transversally theme in the curriculum of health courses and, also, the need to deconstruct cultural and gender issues in society. This study has some limitations characteristic of qualitative studies, as be delimited in time and group that has been developed, so have no intention to generalize the results. However, its contribution is the deepening of the theme and its implications for possible changes in formation of Nursing and Health.

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