Coping with domestic violence against children and adolescents from the perspective of primary care nurses

ABSTRACT

Objective

To analyse the actions reported by primary care nurses in the fight against domestic violence against children and adolescents.

Methods

Qualitative research conducted at five family health centres in the state of São Paulo, Brazil. Data were collected in the second half of 2013 through semi-structured

Results

Two thematic cores emerged: “Public policies identified by the nurses” and “Nurses’ actions regarding violence permeated by fear and conflicts”. The nurses were familiar with public policies, but they were unable to put them into practice; they were unprepared to identify and cope with the violence; they did not participate in training courses; they were afraid to report the detected cases of violence.

Conclusion

The main limitations to the practical work of nurses are work burden, lack of security, and the dynamics of work that is not articulated with the protection network, which causes the underreporting of cases of domestic violence.

Domestic violence; Primary healthcare; Community health nursing; Child; Adolescent

RESUMO

Objetivo

Analisar as ações relatadas por enfermeiros da atenção básica no enfrentamento da violência doméstica contra crianças e adolescentes.

Métodos

Pesquisa qualitativa, realizada em cinco Unidades de Estratégia de Saúde da Família do Estado de São Paulo, Brasil. Dados coletados no segundo semestre de 2013 através de entrevistas semiestruturadas com cinco enfermeiras e analisados através de análise de conteúdo, modalidade temática.

Resultados

Emergiram dois núcleos temáticos: “Políticas públicas identificadas pelas enfermeiras” e “Ações das enfermeiras diante da violência permeadas por medos e conflitos”. As enfermeiras conheciam as políticas públicas, mas não conseguiam colocá-las em prática; estavam despreparadas para identificar e enfrentar a violência; não participavam de cursos de capacitação; temiam notificar os casos detectados de violência.

Conclusão

As principais limitações ao trabalho prático dos enfermeiros são a sobrecarga de trabalho, a falta de segurança e a dinâmica de trabalho desarticulada com a rede de proteção as quais levam à subnotificação dos casos de violência.

Violência doméstica; Atenção primária à saúde; Enfermagem em saúde comunitária; Criança; Adolescente

RESUMEN

Objetivo

Analizar las acciones relatadas por enfermeros de la atención básica en el enfrentamiento de la violencia doméstica contra niños y adolescentes.

Método

Investigación cualitativa, desarrollada en cinco Centros de Salud de Familia del estado de São Paulo, Brasil. Datos recolectados en la segunda mitad de 2013, mediante entrevistas semiestructuradas con cinco enfermeras y analizados a través de análisis de contenido, modalidad temática.

Resultados

Emergieron dos núcleos temáticos: “Políticas públicas identificadas por las enfermeras” y “Acciones de las enfermeras ante la violencia permeadas por miedos y conflictos”. Las enfermeras conocían las políticas públicas, pero no lograban colocarlas en práctica; no estaban preparadas para identificar y enfrentar la violencia; no participaban de cursos de capacitación; temían notificar los casos detectados de violencia.

Conclusión

Las principales limitaciones para el trabajo práctico de las enfermeras son la sobrecarga de trabajo, la falta de seguridad y la dinámica del trabajo desarticulada con la red de apoyo, que conducen a subregistro de casos de violencia.

Violencia doméstica; Atención primaria de salud; Enfermería en salud comunitaria; Niño; Adolescente

INTRODUCTION

Domestic violence is a violation of human rights. Between 1980 and 2010, the number of young murder victims rose 346%, according to the deaths information system of the Brazilian ministry of health. During this period, 608,492 children died as a result of violence and accidents, which are external causes considered preventable by the World Health Organisation. In 2012, the murder rate was 13 for every 100,000 children and adolescents, which puts Brazil in the 4^th position of a list of 92 countries⁽¹⁾.

Acts of violence committed principally against children and adolescents are hindering the development of this population, and have become a major global public health problem. Violence is a secular problem that affects all social classes, ethnic groups, religions, races, and cultures. Thus, violence cannot merely be considered a phenomenon of epidemiology or of social sciences; it must be analysed from the paradigm of complexity and countered by means of interdisciplinary practices⁽²⁾. Since domestic violence was considered a problem in social and legal fields for many years, health workers made no efforts to prevent, detect or intervene in cases of domestic violence⁽³⁾. A multidisciplinary assessment of health professionals could provide a global perspective of this problem, broaden the scope of information and shed additional light on the results. Consequently, there has been a growing number and variety of suggestions to implement public policies that help reduce domestic violence⁽⁴⁾.

Domestic violence can be defined as “any violent act or omission committed inside or outside the home by any family member or person who assumes the parental role and has power over the other members”⁽³⁾. Seeking to ensure full protection to children and adolescents, Article 4 of the Statute of the Child and Adolescent (ECA)⁽⁵⁾ establishes the following: “It is the duty of the family, the community, society at large and the government to ensure, with absolute priority, the enforcement of children’s rights pertaining to life, health, food, education, sport, leisure, professional training, culture, dignity, respect, freedom, and coexistence with family and community”.

Although the family represents the first link of individuals with the society, and it is where people expect to find protection, warmth, the transfer of cultures, and educational practices, this setting can often be threatening and harmful to the development of individuals. In 2011, approximately 63% of medical care for children and teenagers from 1 to 19 years old was related to domestic violence, according to the Brazilian case registry information system (“Sistema de Informações de Agravos de Notificação”)⁽¹⁾.

The consequences of domestic violence can haunt individuals throughout their lives. The victims of domestic violence have a greater tendency to lead a criminal life, to get involved with harmful substances, to exhibit suicidal behaviour and self-injury, to suffer from anxiety, depression, personality disorders, psychosis, and to have difficulties in establishing interpersonal and work relationships. Most of these victims try to solve their social frustrations with narcotic substances and crime, which feeds the cycle of violence⁽⁶⁾.

Some studies have only recently included the actors who are directly involved in domestic violence against children and adolescents and who were not previously considered, despite their role as the first contact between the victims and society, and as the protectors of these victims. Nursing care that targets people, their needs and the multidimensionality of human beings should be considered^(7-8).

In recent years, nurses of all areas have become increasingly involved with promoting, protecting and recovering the health of children and adolescents, especially in schools and in units of the family health strategy (“USF”). Therefore, it is extremely important to prepare these professionals to cope with and help prevent violence against children and adolescents. In the nursing profession, prevention is considered the best way to tackle the problem of violence⁽⁸⁾. In the long term, establishing a preventive mindset regarding the phenomenon of violence could change of the current scenario. Our study question is: “how can we create actions that help primary care nurses cope with domestic violence against children and adolescents?”.

Literature on the insertion of nurses who provide care for young victims of domestic violence is still in the early stages, especially regarding more comprehensive approaches and in the field of primary care^(2-8). Therefore, the participation of nurses in the confrontation and fight against domestic violence toward children and adolescents gained social relevance and can trigger interest on an issue that could improve the knowledge of nurses and other health workers, and reveal ethical and legal issues of professional interest. Given this scenario, the aim of this paper is to analyse actions reported by primary care nurses who are confronted with domestic violence against children and adolescents from the perspective of comprehensive care.

METHODS

The research was based on a qualitative approach, which includes the study of the history, relationships, beliefs, representations, and opinions according to the interpretations of individuals regarding (i) their way of life; (ii) how they construct their artefacts; and (iii) themselves, especially how they feel and think. This approach also shows barely known social processes related to private groups that can allow the construction of new approaches, the review of existing approaches, and the establishment of new concepts and categories during the investigation. The present study is configured as social strategic research to understand reality and insert this reality into the proposed objective⁽⁹⁾.

The present investigation was carried out in primary care institutions in five USF of the state of São Paulo, Brazil. Five nurses participated in the study; one from each USF. The main criteria adopted for selecting the USF were: the presence of at least one nurse; minimum of 6 months since USF implementation; USF connected to the University of São Paulo.

The universe of the study was defined by the criterion of saturation of information in the statements of five subjects. Data were collected through semi-structured interviews conducted with the five nurses, with the following main issues: (1) What do primary care nurses do to cope with domestic violence against children and adolescents and their families at the USF? (2) What safety network do the nurses of the USF know of and use to cope with domestic violence against children and adolescents?

The interviews were conducted and recorded by the researchers in the second half of 2013 according to a script with questions related to the object of study. The nurses’ statements were identified with the letter E followed by the number of the interview to protect their privacy. The study protocol was approved by the Research Ethics Committee of the Centro Saúde Escola da Faculdade de Medicina – USP, process 248. The researchers explained the aim of this study to the participants, who then signed an informed consent statement before being interviewed.

The data were analysed and categorised using thematic content analysis, which consists of discovering the core of meaning in communication that is associated with the analytical objective, considering the everyday statements of people as the purest and most sensitive form of social relations. After skim reading the nurses’ statements, the data were organised and categorised according to the units of significance that emerged from the testimony of the subjects⁽⁹⁾. The core ideas extracted from these documents were used to organise the thematic cores listed in the following section.

RESULTS AND DISCUSSION

The study participants were women between 30 and 55 years of age, with higher education degrees in nursing. The professional experience of these nurses ranged from 8 to 27 years, of which 6 to 12 years were spent working in the field of family health. All the nurses reported that their current occupation was not their first job, and that they had previously worked in basic health units, hospitals, and other USFs. Three interviewees claimed to have received training for the USF. Only one of these three nurses stated she had been trained on the subject of domestic violence. The five nurses who worked at the USF were interviewed at their workplace.

Analysis of the collected material led to the following thematic cores: “Public policies identified by the nurses” and “Nurses’ actions regarding violence permeated by fear and conflicts”.

Public policies identified by nurses

The statements of the professionals revealed that they were aware of the public policy and the importance of events offered by the municipal department of health to help them fight violence. However, they give priority to other activities such as consultations, visits and other technical procedures due to the organisation of work at the USF, as identified below:

[...] Well, there are government events where people discuss how to deal with this problem, they discuss the cases and help people who work in the field of healthcare. When it’s possible, our team attends, but it’s complicated due to lack of time and the duties at the unit. (E5)

The practice and theoretical difficulties faced by the nurses and other public health professionals are notorious, and discourage teams to effectively fight domestic violence against children and adolescents, as shown in the line below:

[...] The health department offers workshops, some events that help a lot. But here at the unit we can´t cope because of the staff shortages. (E3)

The nursing professionals often feel helpless and unaware of the procedures they must perform, which leads to physical and emotional strain and dissatisfaction with their own work⁽¹⁰⁾. Nurses have difficulty reporting cases of violence, and some do not know what they are supposed to report and generally notify the cases of physical or sexual violence. These professionals do not receive information from the family, which prefers to keep the violence a secret, and in many cases they stress the ineffectiveness of the child protective services regarding the reported case and the frustrated resolution of the notification⁽¹¹⁾.

This study also found that the nurses frequently failed to deal effectively with the domestic violence due to the high work load, staff shortages and lack of training, as shown in the following statements:

[...] So the health department is actually trying to do something, and that is probably the right path, isn’t it? Start, train the workers to deal with this type of thing, which they don´t know how to do, fear, insecurity, if asked I am sure they would help. They are readily available people. They are very committed to that, aren’t they? (E2)

The reality of the five visited USFs reveals that the health department must offer solid actions that train nurses to cope with domestic violence and put the learned content into practice. However, the statements below show that they unable to attend these training programmes.

[...] The health department sometimes calls us to talk and always offers tips on how to proceed in cases of violence. To teach as how to be suspicious, and how to help prevent violence. Unfortunately we couldn’t go, could we? We had other activities and we couldn’t go. (E2)

It is of the utmost importance that the public authorities include guidelines on how to improve the technical and legal support for health professionals to help them proceed in accordance with the recommendations of the Unified Health System⁽¹²⁾. Therefore, it is imperative to institutionalise the conditions of safety and support for healthcare professionals in order to establish the notification as routine in health institutions. This is an important objective that may be extremely difficult to achieve in cases of intense local criminality.

The health professionals mentioned their lack of preparation to cope with family violence against children and adolescents, especially to identify whether, for example, a case of omission is the result of negligence or bad financial conditions of the family. They attempted to medicalise the phenomenon due to difficulties in coping with the social and health promotion aspects of the problem.

Currently, many nursing professionals are unprepared and uninformed of the public policies that protect children and adolescents, and consequently fail to notify suspected cases of violence witnessed at the health services⁽¹³⁾. The professional training of nursing has been singled out as one of the main strategies to overcome these barriers^(12-13). In addition, health workers should be capable of perceiving the problem of violence from a comprehensive, dialectic, and objective reality-based standpoint, rather than merely detect warning signs. This capability would help them recognise the vulnerabilities and find methods of intervention⁽¹⁴⁾.

Domestic violence is part of the agenda of nursing professionals, but there is no specific project to prevent and combat this type of violence or a public policy that focuses on training workers to deal with this issue⁽¹⁵⁾. Due to the complexity and specificity of the subject of domestic violence, it is essential to share the quest for knowledge and proposals for action programmes, diagnosis and treatment of the phenomenon, and train all the professionals involved to appropriately and efficiently protect the victims⁽¹⁰⁾.

To ensure the comprehensiveness of care for children and adolescents there must be a training strategy and guidelines for healthcare workers that target the continuity of care and the articulation of the actions of support networks. It is therefore important for professionals to detect situations of domestic violence, report and notify the cases to the competent authorities, and monitor the victims and their families. In theory, these actions could change the violent behaviour of these families.

Nurses’ actions regarding violence permeated by fear and conflicts

This thematic core was used to explore the actions of nurses when confronted with cases of violence and the feelings that accompanied their actions. The testimony of the nurses who worked at the USF revealed that they were afraid to report detected cases of domestic violence according to the guidelines of public policies, as shown below:

[...] We identify and notify the health department, but we don´t touch child protective services. If the person wants to, if the agent is willing we tell them “you can talk to the child services officer to help you”, but even then we are a little apprehensive because it’s not really going to help. You know what? [...], the counsellors don’t do a good job, those who work have this type of attitude, they treat us like the enemy, so we risk our lives, and that´s not right, is it? We have to protect our families. (E1)

[...] has the notification file of the department of health, but that file is statistics, to create laws for the victims. We have this file here at the unit and when there is a case we send it.We have child protective services, but we don’t like to work with them, the staff is unprepared, so we are basically lost. (E4)

Although the nursing professionals who deal with cases of violence are exposed to an intense emotional burden and risk in cases of reported abuse⁽¹⁴⁾, they need to engage in preventing violence and improving the quality of health services in order to help create a fairer, more democratic and supportive society. This engagement would also enable them to recover a broader social, political and moral commitment in relation to their professional praxis, considering that each professional, regardless of work area, is responsible in some way for the children and adolescents who are victims of violence⁽¹⁵⁾.

The present study showed that, despite the concern of nurses with preventing domestic violence against children and adolescents, their performance is limited to notifying suspicious or confirmed cases of violence. After referring the victims to child protective services, the nursing professionals stop monitoring the outcome. Once the notification of violence involving children and adolescents results is formally processed, the nurses exclude themselves from the process for reasons of personal safety or convenience.

One of the most significant points found in this study was the fear that health workers feel in relation to domestic violence. They often felt intimidated by the reactions and actions of the aggressor, and by the threats of the families of the victims toward the health professionals, especially those who work at the USF. Moreover, the ties and proximity of the USF with these families increases the fear of nurses regarding the fight against domestic violence, as shown in the statements below.

[..] It’s really hard for health workers, especially in a place where people know us by name, the agents live in the area, it’s all very close knit, isn’t it? (E2)

[...] Sometimes I feel helpless, scared, clueless as to how I should act, I’m afraid my insecurity will show. (E5)

[...] So, here at the unit we have few cases of violence against children or adolescents, but we are also scared, you know.Fear of the reaction of the aggressor [...] But it’s hard, you know, because even knowing about this aid, we are still afraid, afraid of the aggressor, afraid that something will happen to us. (E4)

In this study, the nurses’ statements indicate that the feeling of fear contributes to the underreporting of cases of domestic violence against children and adolescents. The following statement is a typical example of this problem:

[...] Reporting violence scares the team because we often know about it, we realise that the violence occurs, but the family does not agree with that, so reporting is the same as filing a complaint because your name is there, it’s all there, it’s really complicated. (E2)

In practice, the nursing professionals were afraid to report domestic violence and delegating this role to other professionals. Transferring cases of violence to other professionals or sectors demonstrates that the nurses face several challenges. One of these challenges is the inability to understand that they are an important part of the process to confront such a complex and multicausal phenomenon as domestic violence⁽¹⁵⁾. The results of this study corroborate the report that the fear of health professionals of confronting the aggressor is very present in public health institutions, and may be the cause of their unwillingness to adopt protective measures and feelings of helplessness to cope with the phenomenon of domestic violence⁽¹⁵⁾.

It should be noted that, according to Article 13 of the ECA⁽⁵⁾, the notification of cases of suspected or confirmed violence against children and adolescents is mandatory for health professionals. Besides generating a formal complaint, the notification should trigger a set of protective actions for the victims. The resistance of health workers to report these cases is chiefly based on negative experiences or the persecution of the families of the reported victims⁽¹⁶⁾.

The main causes of underreported cases of violence against children and adolescents mentioned by health workers of the ESF are: lack of preparation and knowledge; lack of structure of the support network; lack of protection for the workers who report cases; fear of lawsuits related to these reports, such as testimony and attendance at hearings; and the unsatisfactory performance of the protective services regarding many reported cases of domestic violence⁽¹⁶⁾.

The data of the present study show that the establishment of support networks for health professionals is one of the largest and most complex challenges to be faced by the government to reduce the levels of underreported violence against children and adolescents. This finding can be identified in the following statement:

[...] Because if we reported everything, even the things we suspect are violence, we would probably have other figures and actions and public policy to take care of it. (E2)

Assistance to the families involved in situations of violence is essential to humanise and qualify care. Encouraging the establishment of family ties and creating awareness among these workers is also required if they are expected to perceive situations of domestic violence because, in most cases, these situations are covered or “masked” by other complaints ⁽¹⁷⁾.

FINAL CONSIDERATIONS

The results of this study allowed the identification of actions of the municipal health department to combat domestic violence against children and adolescents from the standpoint of primary care nurses. The nurses’ statements show that there are initiatives by the public authorities, but that the professionals have trouble participating in the offered training activities due principally to the workload at the health units. The lack of security and the dynamics of work that lacks articulation with a protection network, such as child protective services, are other limitations that affect the practical work of nurses.

The fear of nurses in relation to the aggressor, the lack of training and actions against domestic violence, such as prevention, notification, referral and monitoring of victims, hinder the fight against domestic violence and should be valued not only by nurses, but also by all the professionals who provide care for children and adolescents.

Therefore, regarding the complexity of domestic violence against children and adolescents, it is necessary to create multidisciplinary and intersectoral actions that seek to improve the living conditions of these victims, as well as elaborate public policies that guarantee the constitutional rights of these populations. In addition, continued education programmes must be implemented to empower nurses to deal with domestic violence against children and adolescents. These programmes can extend the knowledge for public policies that protect victims of violence, as well as support the safe exercise of nursing professionals in the protection of children and adolescents in situations of domestic violence. Finally, the nurse should be viewed as the transforming agent of practices by means of permanent education; discussion of cases in interdisciplinary and intersectoral teams; family-oriented and community-oriented actions, as opposed to merely youth-oriented actions; and longitudinal actions throughout the care process for children and adolescents, from primary to hospital care.

The main limitations of this study are the generalisation of the observed results and the need to complement these results, especially in relation to family care. More comprehensive research and programmes that involve the aggressor, the victim, and the community are therefore recommended.

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Publication Dates

• Publication in this collection
  2016

History

• Received
  21 May 2015
• Accepted
  20 May 2016