NURSING CARE FOR WOMEN IN SITUATIONS OF SEXUAL VIOLENCE: SOCIAL REPRESENTATIONS OF NURSES

ABSTRACT

Objective:

to know the social representations of nurses about the nursing care provided to women in situations of sexual violence.

Method:

qualitative, exploratory-descriptive study, based on the Social Representations Theory, conducted in a reference center of a University Hospital in southern Brazil. Data collection was performed through semi-structured interviews with 20 nurses. The interviews were submitted to content analysis with the support of the Qualitative Data Analysis Mine software.

Results:

they reveal, in the experience of the care provided, representations such as: conducts developed by nurses; difficulties encountered in the development of care activities for women in situations of sexual violence; and suggestions to improve care for these women.

Conclusion:

the social representations of nurses about the nursing care provided to women in situations of sexual violence are anchored in the execution of protocols in a humanized way, objectified in the notion of reception.

DESCRIPTORS:
Sexual Violence; Sexual Offenses; Women; Nursing Care; Social Theory

RESUMO

Objetivo:

conhecer as representações sociais de enfermeiros acerca do atendimento de enfermagem prestado às mulheres em situação de violência sexual.

Método:

estudo qualitativo, tipo exploratório-descritivo, fundamentado na Teoria das Representações Sociais, realizado em um centro de referência de um Hospital Universitário do Sul do Brasil. A coleta de dados foi realizada por meio de entrevistas semiestruturadas, com 20 enfermeiros. As entrevistas foram submetidas à análise de conteúdo com apoio do software Qualitativa Data Analysis Mine.

Resultados:

revelam, na vivência do atendimento prestado, representações como: condutas desenvolvidas pelos enfermeiros; dificuldades encontradas para o desenvolvimento das atividades assistenciais às mulheres em situações de violência sexual; e sugestões para melhorar o atendimento a essas mulheres.

Conclusão:

as representações sociais dos enfermeiros acerca do atendimento de enfermagem prestado às mulheres em situação de violência sexual estão ancoradas na execução de protocolos de forma humanizada, objetificada na noção de acolhimento.

DESCRITORES:
Violência Sexual; Delitos Sexuais; Mulheres; Assistência de Enfermagem; Teoria Social

RESUMEN

Objetivo:

conocer las representaciones sociales de las enfermeras sobre la atención de enfermería prestados a las mujeres en situaciones de violencia sexual.

Método:

estudio cualitativo exploratorio-descriptivo, basado en la Teoría de las Representaciones Sociales, realizado en un centro de referencia de un Hospital Universitario del Sur de Brasil. Los datos se recogieron mediante entrevistas semiestructuradas a 20 enfermeras. Las entrevistas se sometieron a un análisis de contenido con el apoyo del software Qualitative Data Analysis Mine.

Resultados:

revelan, en la experiencia de los cuidados prestados, representaciones tales como: comportamientos desarrollados por las enfermeras; dificultades encontradas en el desarrollo de las actividades de atención a las mujeres en situación de violencia sexual; y sugerencias para mejorar la atención a estas mujeres.

Conclusión:

las representaciones sociales de los enfermeros sobre la atención de enfermería prestada a las mujeres en situación de violencia sexual se corresponden con la ejecución de protocolos de forma humanizada, objetivada en la noción de acolchamiento.

DESCRIPTORES:
Delito Sexual; Delitos Sexuales; Mujeres; Atención de Enfermería; Teoría Social

INTRODUCTION

The act of coercion conceptualizes sexual violence to the person in this situation, and some forms of its presentation are: unwanted sexual comments/assaults, attempt to perform a sexual act, the sexual act itself in a consummate way in any of its possibilities or acts that lead to sex trafficking. In Brazil, the legal concept of rape corroborates this concept of sexual violence when it inserts terms such as embarrassing, threatening, practicing, or allowing the libidinous act¹.

This type of violence against women can cause female genital mutilation and early and forced child marriages. Such situations, which often occur since childhood, represent 30% of reported cases worldwide, and intimate partner violence represents another 30% of reported cases, driving the rise of feminicide worldwide². Brazilian studies addressing the performance of health services and professionals in the face of Intimate Partner Violence (IPV) reveal the realities and limits of health practices related to the fear of patients in talking about the violence they suffered, the biomedical model of care, and the difficulty in the relationship and performance of the public security sector^3-4.

Professionals who provide care to women victims of sexual violence should act cautiously and respectfully, given the fragility of women in this situation, guiding these women as to the intra and intersectoral network that exists to protect them. To this end, they must also be aware of the correct identification of victims and notification of cases. These sectors must act in an integrated manner so that the victim has humanized, safe, comprehensive, complete, and quality care⁵.

The Social Representations Theory (SRT), adopted as a theoretical framework in this study, with a social approach, presupposes focusing on the systems of beliefs, evaluations, and social norms, characteristics of a society or certain groups, giving meaning to the behaviors of individuals creating social differences through general principles. Phenomena with moral aspects can be studied by evaluating personal and collective aspects, thus related to public and institutional aspects⁶.

Referring to the nursing area, the social representations of nurses regarding nursing care for women in situations of sexual violence are of paramount importance for identifying the thoughts that drive their care and in the collective construction that can favor the practice of nursing in the care of these women.

The transversality of violence permeates several sectors of society, including security, health, and justice. Nursing sometimes enables the link between these sectors. To give visibility to the nursing work to women in situations of sexual violence, this study aims to know the social representations of nurses about the nursing care provided to women in situations of sexual violence.

METHOD

This is a qualitative, exploratory-descriptive study based on the Social Representations Theory. This theory makes it possible to reveal conflicts, disagreements, and agreements of phenomena that permeate the daily lives of social classes and reveal nuclei that justify resistance and/or transformations in the way of learning from reality⁶. Thus, it is proposed an analysis beyond the uniqueness of the professional individual, seeking the depth of representativeness of this group.

The study was conducted in Florianópolis-SC, Brazil, with nurses from the Maternity Hospital of a University Hospital, a reference for the care of women in situations of sexual violence.

The sample, intentional, totaled 20 participants, selected by convenience, with no refusals to participate. It was determined by theoretical saturation of the data⁷ during data collection and analysis and considered when no new element was identified, and the addition of new information was no longer necessary, as it would not change the understanding of the phenomenon.

To include the participants, the following criteria were observed: nurses who had already provided nursing care to women in situations of sexual violence in the first care after the violence; and/or in an outpatient setting; and/or in the care of women for the Legal Termination of Pregnancy. As exclusion criteria, we considered professionals with less than six months in the sector who had no experience caring for women in situations of sexual violence, professionals who were away due to health problems and vacations.

Data collection was conducted between July and August 2020 by the main researcher through a semi-structured interview, directed by the following guiding questions: “How is your care provided to women in situations of sexual violence?”; “What do you think of the nurse’s conduct towards women in situations of sexual violence?”. The interviews were conducted in rooms of the hospital unit and virtual rooms via the Zoom platform, with prior scheduling as requested by the participants. The content was recorded in audio with the consent of the participants and later transcribed.

The data were analyzed using the content analysis technique, supported by the Qualitative Data Analysis (QDA) Miner software⁸. The content analysis respected its respective phases: pre-analysis; exploration of the material; and treatment of results, inference, and interpretation⁹. To ensure the methodological rigor of the study, the procedures for data collection and analysis were described, as well as the theoretical perspective used in the analysis of the results, interpreted within the framework of the Social Representations Theory⁶. Besides, the conduction of the study and production of the report complied with the Consolidated criteria for reporting qualitative research¹⁰.

The present study was approved by the Research Ethics Committee of the Federal University of Santa Catarina, number of the Certificate of Presentation for Ethical Appreciation 28859220.9.0000.0121, consolidated opinion No. 3,979,495. The study fully complied with the standards of Resolutions No. 466/12 and No. 510/16 of the National Health Council and its supplements.

The study participants signed the Free and Informed Consent Form, after being informed about the objectives of the investigation. To preserve the anonymity of the interviewees, their names were hidden and replaced by an alphanumeric code composed of the prefix “Nurse”, followed by a cardinal number.

RESULTS

From the analysis of the interviews, from the perspective of understanding the social representations, three thematic categories emerged: Conduct developed by nurses; Difficulties encountered in the development of care activities for women in situations of sexual violence; and Suggestions to improve care for these women.

In the first thematic category, Conducts developed by nurses, it is observed that the care conducts are anchored in the care provided to women, and that the performance of good care will promote the good development of continuity of care, following the protocol instructions.

It is, first of all to receive, to give a respectful reception to this woman. Here in the hospital, when we have a woman who has been a victim of sexual violence, we open our protocol, to do all the tests, to check the vital signs, in short, it is the nurse who calls the multidisciplinary team [...] a team that is trained for this, to come to assist this woman and proceed with all the follow-up. If she is a person who suffered the violence and went to the hospital afterwards, then all the tests and everything are done, this patient receives the morning-after pill and everything, and when then she is a patient who comes to the legal termination of pregnancy, then this team is also called and then she also receives multi care. (Nurse 18)

When the reception is performed, the service is performed privately and as agile as possible, starting with collecting the violence history and directing it to other professionals involved in the service and, when requested by the woman, to the agency responsible for the corpus delicti examination.

It is to preserve this woman, and give her assistance as soon as possible in what is up to me, and what is up to me is the assistance of the medical team, try to expedite her care so that this bureaucratic and also assistance procedure for her is resolved as soon as possible so that she can go home, or even when she accepts to make a complaint, if she brings the Police Report we can call the Institute of Forensic Medicine (IML) to conduct the corpus delicti examination, and we also do this procedure as soon as possible so that she does not stay here long, and we are always careful not to ask a lot, I always try to enter with some other professional so that I do not ask the same questions or she repeats the same things to several professionals. (Nurse 5)

With the application of the recommended conducts, respect for women in situations of sexual violence is a very raised point when it comes to the conducts performed, besides the need for non-judgment by the professional.

[...] I think it is respect above all and less judgment, I listen to the story if she wants to talk, if she does not want to we do not force it either, I try to pass as much empathy as possible. (Nurse 4)

[...] my conduct regardless of the papers that have to be filled out, the referrals that I have to make, I always take care to come without judgment, take this person who does not accept this (Legal Termination of Pregnancy) and leave it aside, leave outside the door, and here comes the professional who is looking at a human being who was a victim of violence, who did not want that, and that happened, this is my conduct. (Nurse 8)

In the second thematic category, Difficulties encountered in the development of care activities for women in situations of sexual violence, nurses report in their representations situations that directly impact their care, such as the work overload of other professionals of the multidisciplinary team, documentation to be completed for care, relationship with external bodies related to the continuity of care, and active participation in the organizational process of care. The nurses’ distress when they mention these issues is perceived.

[...] every life that comes to a violence, be it acute, or be it a termination, a violence with pregnancy that will not be subjected to those medications and everything, it is a tension, because there are many papers, so you must stop everything to pay attention to that. There is a lot of difficulty in the issue of police reports because the civil police, even before the pandemic, sometimes makes it difficult to come here, to make the report here, they want to do it by phone, and the general institute of expertise also takes a long time to come, that is why I always say the process is slow, it is not only due to the capacity, but the issue of the police part and the expertise part is very slow, added to all this, it is a series of documents that we have to fill out. (Nurse 3)

[...] The physician who attends this patient is also involved in other demands because he attends in the emergency room, so sometimes this patient ends up not being the priority. For example, there is a pregnant woman on the verge of giving birth, she is treated first, and this other victim of violence sometimes gets a little behind, so to speak, she is not so prioritized. (Nurse 7)

[...] it is just another number for our local statistics here, of what we did here in the sector, but we do not get involved, she is not involved in this flow [...]. (Nurse 13)

The third thematic category of this study, Suggestions to improve care for these women, the nurses present suggestions for changes in the current flow of care for women in situations of sexual violence to improve the humanization of care for this specific population.

[...] The only disadvantage I can see is not having a door just for this, it is not like this here in the maternity hospital, I think it should not be even in the others, but here at the University Hospital there are several services, and she is another patient, if there was a specific place for this I think it would also be something that would favor the care for women, for her demand, for her assistance [...]. (Nurse 5)

[...] I do not know if it includes a very delicate issue, we (team) also talk and we do not think it is right, this type of procedure (Legal Termination of Pregnancy) is performed there in the OC, with childbirth, they stay in the recovery room with mothers and other babies, in short, after everything that happened, both violence and abortion in general. (Nurse 14)

[...] when suddenly discussing and proposing some help, in a vision, in a statistic that may become a better health policy, to avoid this type of situation, let’s suppose. (Nurse 13)

DISCUSSION

When analyzing the interviewees’ statements, it is clear that nursing care for women in situations of sexual violence is anchored in reception. There is a predominance of speeches related to the reception of women overlapping the other stages of continuity of care, so that the quality of the reception allows the development of women’s trust for the execution of protocol conducts.

Nursing care allows for a closer relationship between the professional and the clients. This established relationship enables the understanding of health needs beyond the clinical; they are actions and feelings of understanding, attention, responsibility, and zeal¹¹. In this perspective, nurses develop their practices holistically, covering biological, psychological, emotional, and social needs¹². The initial contact of nursing with this woman sometimes enables the development of the necessary trust for the woman to report the event more safely, enabling individualized care on top of the recommended conducts. This care allows the professional to know the meanings of the non-consented invasion of the woman’s body, enabling the construction of the representation about sexual violence, considering personal, cultural, and social aspects⁶.

The same initial category showed that nurses value the privacy of women and the agility of care, with the support of the multidisciplinary team and other bodies (civil and scientific police) involved for integrality of care, when the woman wants. Women must be questioned about their complaints and doubts, continuing the care, ensuring the integrality of care. Interdisciplinarity is anchored in the perspective of the transformation caused in professionals by different experiences and realities. Each professional rebuilds himself/herself in the practice of the other, expanding the approach of care and making care resolutive.

A previous study corroborates the nursing care provided to women in situations of sexual violence by the participants of this study, where this professional must be able to provide care in a private and individualized manner. For this, it is necessary to apply the concept of comprehensive care, including availability, responsibility, and companionship, besides the good emotional state of the professionals, which impact the health of those being cared for¹³.

The conduct of Sexual Assault Nurse Examiners in countries such as the United States and Canada follows the national protocol of forensic examination for sexual assault, following the national standards of training of the United States Department of Justice¹⁴. This protocol directs care as a priority and guarantees the victim’s privacy. The components of the forensic examination are initial contact, screening, and admission, personal health documentation, history collection, photography, evidence and examination collection procedures, identification of alcohol and drug use, STI assessment and care, pregnancy risk assessment and care, discharge and follow-up, and court attendance when requested¹⁵.

A study conducted in Brazil with nurses who assisted women in situations of sexual violence revealed that all participants recognized the importance of collecting and preserving traces after sexual violence, but 93% of participants were unaware of the techniques for collecting and managing traces¹⁶. This fact can be justified by the fragility of the qualification of professionals who work in the care of women in situations of sexual violence due to the lack of approach to the topic during undergraduate studies, aggravated by the lack of training for this type of situation in the services¹⁷.

Regarding the second category, Difficulties encountered in the development of care activities for women in situations of sexual violence, it was observed that nurses report work overload of the multidisciplinary team, excess documentation to be completed, and lack of integration between the agencies responsible for care. These difficulties are responsible for the excessive stress of these professionals, which sometimes ends up weakening the care and making it time-consuming and extending the length of stay of women in the hospital environment.

Nurses experience moral distress when they cannot develop their activities due to judgments of personal and professional values, developing internal and/or external constraints when they feel powerless in the face of the difficulty of acting according to their own conscience. Moral deliberation is evidenced by the balance between compliance with the deontological code and the subjective criteria of professional experience¹⁸.

Sometimes, it is up to the nurse to deal with and conduct conflicting situations. Often, the care of women in situations of sexual violence and the process of possibility and perspective for the Legal Termination of Pregnancy develop moral distress. A possibility of help is the moral deliberation among the professionals involved in the care, prudently and reasonably, considering the duties of the profession and the values of the professional.

Often women’s health is compromised due to the violation of their human rights. This commitment occurs when thousands of women worldwide risk their health and their lives by undergoing procedures that should be completely safe, considering the advances of modern medicine. Measures that restrict women’s freedom to control their own bodies increase the incidence of death from abortion worldwide^19-20. Even with the possibility of legal termination of an unplanned pregnancy desired by the woman, there are still professionals who have a conscientious objection to the care of these women.

Studies identify as difficulties for the development of work activities the work overload of nurses related to time management, inadequate staff dimensioning, high patient turnover in hospital units, among other factors, which also extend to the entire multidisciplinary team. It is necessary to plan the work related to individual and/or collective demands to reduce work overload and reduce the possibilities of error of professionals in the care of patients^21-23, in this case, women in situations of sexual violence.

From this study, it was noticeable the difficulty of articulation between the sectors responsible for the integrality of care to women in situations of sexual violence, that is, the comprehensive care directed to these women. Given the reports, there are obstacles to the continuity of care, related to the difficulties imposed by the public security service in carrying out the police report of these women, necessary to call the medical-legal expertise service, which, in turn, when called, also does not treat this type of care as a priority, delaying the entire care process. The scientific databases do not have information to justify this difficulty in articulating the services. Thus, an important gap in the knowledge to be filled is identified.

The third category consists of Suggestions to improve care for these women, anchored in the change in the flow of care, starting with the exclusive access door for cases of sexual violence, with a qualified and specialized team in this service. They point out that Legal Terminations of Pregnancies are no longer performed in obstetric centers to minimize traumas and memories of the therapeutic procedure and contact with other mothers and babies. Finally, the development of new public policies that are enforced, with effective articulation between health and justice.

Such suggestions make up the social representations of the nurses participating in this study, directing them to a reconstruction of the care flow through the consensual universe considering scientific knowledge, shaping the reality6 of this care.

It is considered a limitation of the study to perform it in a single reference hospital for the care of women in situations of sexual violence, which makes it impossible to generalize the results since the nurses have experiences that vary according to the location and culture. However, its relevance lies in the fact that it is a qualitative study that points out subjectivities arising from social representations, which combine with other studies conducted in other scenarios, offering contributions to nurses through the reflections exposed here.

CONCLUSION

The study of the social representations of nurses about the care provided to women in situations of sexual violence shows, in its results, conducts developed by nurses, difficulties encountered in the development of care activities for women in situations of sexual violence, and suggestions to improve care for these women.

Concerning the conducts developed by nurses, the importance of adopting protocols is highlighted, with “reception” having a prominent position. When connected to the others, which are also relevant to the process of representational elaboration, this term reveals in which aspects and ideas are anchored: maintaining the privacy of women and agility of care, supported by the multidisciplinary team, favoring the quality of care. The scope of care delivery is due to the quality of the care provided to women.

The main difficulties identified are work overload of the multidisciplinary team, excess documentation to be completed, lack of articulation and integration of the services involved. It is evident the difficulty of the judicial bodies responsible for prioritizing this type of care.

Concerning the suggestions, nurses, in their social representations, highlight the importance of changing the flow of care for women in the institution where they work to improve the humanization of care. The development of public policies that enable a better flow of care is evidenced in the proposals.

This study provides managers of public health and security services, health professionals, and other sectors with valuable information about the changes needed to improve care. The results are expected to foster discussions about the care of women in situations of sexual violence, providing positive changes for the practice of nurses and guaranteeing women quality care and ensuring the effectiveness of care.

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  Silva RMB, Moreira SNT. Estresse e residência multiprofissional em saúde: compreendendo significados no processo de formação. Rev. bras. educ. med [Internet]. 2019 [acesso em 26 jan 2021]; 43(4):157-166. Disponível em: https://doi.org/10.1590/1981-52712015v43n4rb20190031
  » https://doi.org/10.1590/1981-52712015v43n4rb20190031
• ²³
  Forte ECN, Pires DEP, Martins MMFPS, Padilha MICS, Schneider DG, Trindade LL. Processo de trabalho: fundamentação para compreender os erros de enfermagem. Rev. esc. enferm. USP. [Internet]. 2019 [acesso em 26 jan 2021]; 53:e03489. Disponível em: https://doi.org/10.1590/s1980-220x2018001803489
  » https://doi.org/10.1590/s1980-220x2018001803489

• *
  Article extracted from the master’s dissertation “Social Representations of Nurses about the care provided to women in situations of sexual violence”. Federal University of Santa Catarina, 2020.

Edited by

Associate editor:

Tatiane Herreira Trigueiro

Publication Dates

• Publication in this collection
  13 June 2022
• Date of issue
  2022

History

• Received
  30 Jan 2021
• Accepted
  07 Feb 2022