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Enfermería Global

versión On-line ISSN 1695-6141

Enferm. glob. vol.20 no.63 Murcia jul. 2021  Epub 02-Ago-2021

https://dx.doi.org/10.6018/eglobal.460031 

Originals

Approach about sexual violence against women in the nursing undergraduation course

Francisca Alanny Rocha Aguiar1  , João Víctor Lira Dourado2  , Niviane Silva de Sousa1  , Antonio Rodrigues Ferreira Júnior3  , Luiza Jane Eyre de Souza Vieira3  , Raimunda Magalhães da Silva3 

1 Centro de Ciencias de la Salud, Centro Universitario INTA. Sobral, Ceará, Brasil. alannyrocha2009@hotmail.com

2 Programa de Posgraduación en Salud Pública, Departamento de Salud Comunitaria, Universidad Federal de Ceará. Fortaleza, Ceará, Brasil.

3 Programa de Posgraduación en Salud Colectiva, Centro de Ciencias de la Salud, Universidad Estadual de Ceará. Fortaleza, Ceará, Brasil.

ABSTRACT:

Objective:

Understanding the approach to sexual violence against women in undergraduate nursing.

Method:

A qualitative study developed in a Higher Education Institution located in a medium-sized municipality in the state of Ceará. From April to November 2019, a semi-structured interview was conducted with 15 participants. In the organization of information, thematic analysis and theoretical references of gender violence and skills pedagogy were used.

Results:

Three categories were elaborated regarding the meanings attributed to sexual violence; the approach of the theme through the teaching-research-extension triad at the university; and the possibilities and challenges for the inclusion of the theme in professional training.

Conclusions:

Sexual violence presents itself as a social problem of the condition imposed on women in relation to men. This has gained visibility in the social sphere; however, in training there is still a close relationship for its inclusion.

Keywords: Gender-Based Violence; Sex Offenses; Education, Graduate; Education, Professional; Staff Development; Nursing

INTRODUCTION

Sexual Violence (SV) has presented itself in the last three decades as a growing and accentuated social occurrence. This is one of the most heinous forms of gender violence and human rights violations, corresponding as one of the main indicators of discrimination against women1. It is characterized as any non-consensual sexual activity, which can cause death or disability with greater prevalence among women of reproductive age2.

It is estimated that approximately one in three women (35%) worldwide, suffered from SV on the part of their partner or third parties during their lifetime3. In Brazil, there are records that 66,041 people were victims in 2018, with 81.8% female, 53.8% under 13 years of age and 50.9% black, representing an increase of 4.1% in comparison the previous year. The State of Ceará reported 1,790 sexual crimes, of which 1,525 affected female people, representing one of the highest rates expressed in the country4.

In view of the context that is established as a global problem, this type of violence has claimed spaces for discussion, among which, Higher Education stands out for fostering debates about health-disease situations that affect the population's life. However, it is identified that the training does not express concern with the approach of this theme, as it is still influenced by the biomedical model. In this way, the health problems of people, which are becoming more and more common, are beyond the expertise of health professionals, for example, the nurse who does not know what conduct to adopt in the case of SV5.

Studies show the deficiency of the theme in graduation and the preparation directed to the question, which reproduces an unprepared and incomplete performance. The first contact with the episode often occurs through practice in the health service, which encourages professionals, on their own initiative, to seek different forms of qualification1. This scenario contributes to the fact that many cases of SV go unnoticed by health services, due to the challenges of the professional in identifying them, given the socio-cultural character of the phenomenon2.

Therefore, it is recognized that it is necessary to expand the theoretical-practical debate in the academic community. This action is based on the perspective that undergraduate nursing students will act to face SV and, when faced with cases, they should feel motivated and prepared to contribute to the solution through identification and intervention, as provided for by Technical Standard1.

Faced with what is presented, driven by the interest of researching on the theme that appears to be incipient in the training fields, this study was developed aiming at answering the following research question: How does the SV approach against women in undergraduate nursing?

Thus, the study aims to understand the approach of SV against women in nursing graduation.

MATERIAL AND METHOD

Kind of study

This is an exploratory-descriptive study with a qualitative approach, the latter of which has become essential to deepen knowledge on the subject investigated6. This met the recommendations of the Consolidated Criteria for Reporting Qualitative Research (COREQ)7.

Participants

The research included members of the undergraduate nursing course, distributed as follows: five students, five teachers and five managers, totaling 15 participants. This final size was achieved by closing the sample by theoretical saturation8.

As inclusion criteria for students, it was used: being enrolled in the undergraduate course, participating regularly in classes and developing extracurricular activities. As for teachers, it was adopted: being a nurse, being in the exercise of teaching and being responsible for subjects that addressed violence. Those who were away from academic or professional activities during information collection were excluded.

About managers, it was applied: to present a management position in the dean's office, board and in the course, in addition to being in teaching. However, the managers participating in the research, although they were also teachers, did not respond to teachers' interviews, thus constituting themselves as an exclusion criterion.

Participants were selected unintentionally, considering diversity and access during the development of the research and invited to participate in the study through electronic mail and personal contact.

Scenario

The study was carried out in a Higher Education Institution (HEI), located in a medium-sized municipality in the northern region of the State of Ceará, Brazil. In the area of ​​education, this has been a reference both nationally and internationally, as it ranks first in the Basic Education Development Index9. In higher education, it has more than 50 undergraduate courses, considering the largest university center in the interior of the state.

The IES, in turn, is the largest educational institution in the North, offering undergraduate and graduate courses lato sensu and stricto sensu in classroom and/or distance learning. It establishes itself as an institution committed to Higher Education of quality and technical, scientific and macro-regional economic development. In this way, the choice of the municipality is since it is considered one of the main training centers of Ceará and IES for training professionals to work throughout the State.

Data collect

From April to November 2019, the main researcher accompanied by a previously trained undergraduate student conducted semi-structured interviews, with scheduled time and day, applied individually at the IES facilities and with an average duration of 25 minutes each. These were recorded in audio with the aid of a voice recorder, with the authorization of the participants, to maximize the veracity of the information obtained and facilitate the literal transcription of the testimonies.

The testimony fragments, when presented in the results, were identified and coded by the term ‘Student’, ‘Teacher’ or ‘Manager’ plus the number corresponding to the order of participation in the interviews.

Data analysis and treatment

For the guidance and organization of information, content analysis was used in the thematic modality6. The themes emerged after the distribution, on the board, of the corresponding speeches of the interviewees and the extraction of units of meaning, later, units of context and, finally, the elaboration of thematic categories.

Gender-based violence10 and skills pedagogy11) were also adopted as theoretical-analytical references. Regarding gender violence, Saffioti10 apprehends the broader concept, given the patriarchal function that men determine the conduct of other social categories. Regarding the pedagogy of competences, Perrenoud11 emphasizes the subjective dimension of knowledge, not treating the curriculum as an object, but focusing on training processes.

Ethical aspects

The study respected the ethical aspects postulated in Resolution 466/12 of the National Health Council, which regulates research involving human beings12. A favorable opinion was obtained from the Research Ethics Committee under number 3,234,478 in 2019. All participants signed the Free and Informed Consent Form.

RESULTS

Among the students, there was a predominance of females (04), the age range ranged from 21 to 24 years of age, all of whom declared themselves to be single, mostly adherents (04) to the Catholic religion and belonging to different semesters. About the 10 professionals, there was a predominance of females (07), aged between 32 to 52 years, most (08) were married, all Catholics (10), with training time ranging from nine to 42 years and less than five years of service among the majority (07). Regarding the degree, most had a master's degree (07) followed by a doctorate (02) and specialization (01).

Based on the analysis and organization of the information, three thematic categories were elaborated:

Meanings attributed to SV against women

SV against women reveals itself as a very present issue in contemporary society:

(...) sexual violence against women is very present today. You talk about sexual violence; I believe you are very present. (Teacher 01)

The phenomenon is due to the existence of a social construction of male superiority over female in remote times that permeates the whole history:

(...) this comes from the beginnings of humanity in which the woman, a long time ago, did not even have the right to vote. This already causes a certain superiority of the male sex with the female sex and then this has taken root in men because the woman was inferior. (Student 01)

It manifests itself verbally and/or non-verbally with derogatory connotations and/or through physical contact under the use of force or disability:

It is violence in the most diverse ways, violating women in a physical way, in a verbal way, you can attack her in different ways (...). (Student 05)

However, in view of facing the multiple forms of violence against gender, which have demanded fairer and more dignified conditions for women, the right to not be subjected to aggression is evident and, therefore, respect for the specifics:

(...) sexual violence against women is unaccepTable today, because no woman, she has the right to be raped, against her will. (Student 02)

Teaching-research-extension about SV against women

In the testimony of one of the managers, ambiguity about the approach of SV against women in the curricular contents is identified. This presented ignorance about the existence of the theme in the course subjects and, at the same time, knowledge of the presence in the context of infections:

(...) I can't tell you that because I don't know. I am not up to date on the disciplines, but it does exist within sexually transmitted diseases, certainly there is this approach. (Manager 04)

Although the manager presents a certain imprecision on the theme in professional training, in the teacher's testimony the discussion on the menu of specific subjects was evident, according to the logic of the teacher:

(...) these are themes that are included in the menu and that depending on the teacher who teaches the discipline, he will see different strategies and approaches to do. (Teacher 05)

It is since the course does not have an exclusive discipline on the subject, however, the discussion integrates one or more disciplines based on the presupposition of transversality:

(...) if I understand curriculum content as some specific discipline I would say no, but if I understand curriculum content like, content that can be worked on in one or in several disciplines I would say yes because there is transversality (...) (Manager 03).

Among the disciplines of the curricular matrix of that course, we highlight ‘Women's Health’, ‘Collective Health’ and ‘Health-Disease Process’ in addressing the multiple forms of violence against women, including SV:

(...) I have, Women's Health is worked on, violence against women, when you also work on Public Health you work on the various areas of violence, this can also be worked on in the Health and Disease Process (...) (Manager 02)

With the use of several strategies to mediate the subject in the classroom and make students protagonists in the teaching-learning process, for example, collective dynamics, group discussion and seminars:

(...) I even do it in the form of dynamics, I distribute these concepts on the floor, on paper, students must identify. They will have to separate what these concepts are, they will discuss in the group if all the concepts are really the ones there. Then we have a discussion with the general group. (Teacher 05)

Although the theme is present in the subjects' menu, it is still presented in a discreet and superficial way in the field of knowledge production in the classroom:

(...) there was, yes there was. But then, it wasn’t in a very comprehensive way, it was very succinct. (Student 05)

In other statements, students' contact with the theme was identified beyond the classroom. In supervised internship I and II, respectively, belonging to the 9th and 10th period and to the Primary, Secondary or Tertiary Care field, these are implicated in situations of SV against women:

(...) the students end up seeing a lot of cases too, which is the Supervised Internship discipline. (Manager 05)

The inclusion of the theme has also been present in the research groups of the HEI, as shown:

(...) we have a Sexual and Reproductive Health Research group that addresses it. We have the Humanization Group that addresses it. There is an Elderly Group that speaks. (Teacher 03)

The extension groups presented themselves as another strategy at the HEI to discuss the theme. It was evidenced that these make it possible for the graduate student in the field to encounter social problems, including about SV against women:

We have a particularly good project in partnership with Lar de Ester, where we have experienced serious sexual violence problems there. (Teacher 01)

The extension process was also observed by stimulating interdisciplinarity. The HEI extension group enables shared work through the participation of different areas of knowledge to know-how with a common goal:

(...) the Family Ties Project works effectively with this issue of violence. They are even doing it, together with the law, psychology and pedagogy staff (Teacher 03)

Inclusion of the theme SV against women in training

Despite the curricular content of the subjects on the menu of the undergraduate Nursing course, they are based on technical-scientific aspects that confer legitimated competencies and skills to the profession for health care, the relevance of the SV approach against women:

(...) the theme is important to be addressed in the curriculum. In the curricular matrix, we often worry about training much more technically, we end up forgetting that part of the social. (Manager 05)

The inclusion of this theme in the fields of professional training is considered essential among the participants:

(...) I think it is perfectly prudent, pertinent, relevant and it really is something that needs to be inserted within the University. (Teacher 01)

This is since SV against women is gaining more space in social devices and, therefore, because of the need to encourage discussion in the fields of professional training:

(...) I realize it is which is a topic that is already gaining, it is already gaining greater relevance among people, so we start to realize, and we need to deepen this topic further. (Teacher 05)

Among the possibilities for inclusion in higher education, it is identified the students' own interest in discussing the topic collectively through the disciplines during the class:

(...) I realized that there was a great motivation, a great enthusiasm on the part of the students, they became motivated, they became very enthusiastic in discussing and talking. (Teacher 01)

In addition to the experience of the teacher due to the professional performance in a health service that makes it possible to express concrete situations for a real understanding of the facts:

(...) because I have more than 10 years of strategy, so I have already seen some women. You must have an experience, a greater professional maturity. (Teacher 04)

In this way, the group discussions providing the opportunity to share personal and/or family experiences for the collective regarding some violence suffered, which makes the moment even more productive:

(...) some people reported family experiences, talked about relatives, I found it very productive. (Teacher 01)

However, in other statements, aspects that make the inclusion of the topic as challenging in professional training become evident, among which, the approach to violence against women is identified, especially SV with students in the classroom:

(...) as it is a controversial subject, several professors prefer not to mention the subject and the student, in turn, has already gone through something that he will remember or that will touch the wound of what happened. The teacher does not move, the student in turn, who has a sequel to this, also does not want me to talk. (Manager 1)

It is perceived the deficiency of ownership on the subject by the teacher to mediate dialogues on the IES campus:

(...) there is a difficulty that we do not have ownership of the subject so that we can have ownership of spreading knowledge within the institution. (Manager 05)

Faced with this context, it is evident that there is a need for the implementation of new theoretical and practical aspects that allow the propagation of the theme within the walls of the HEI. For example, the elaboration of an exclusive discipline for issues involving gender:

(...) create a discipline focused on violence and we understand that women, for these reasons of gender, of cultural issues. (Teacher 04)

The organization of scientific events with the participation of experts in the thematic area in question:

In this case, there would be more lectures and more debate, much more debated in the classroom, because the debate in the classroom on this topic is scarce at times. (Student 02)

And, still carrying out activities through the teaching-service dyad that makes it possible for students to participate in the field to experience real situations and implement health interventions:

(...) not only inside the Faculty itself, but interacting with the public, outside. We must have something outside on the outside to be able to make the population more aware of the topic. (Student 03)

DISCUSSION

The findings of this study are like the results of other national and international studies, in which the predominance of female students is identified among undergraduate nursing students, with an average age of 22.6 years, all of whom are single, most adherents to the Catholic attending different semesters13. As for the teachers, it appears that the majority are women, the age range varies between young and old, predominance of married, mostly Catholics, high training time since graduation, variation in service time in teaching and obtaining the title of master followed by doctor and specialist14.

Among the testimonies of the participants, it is evident that the theme in question has gained space and received a focus on the social environment. In fact, violence against women has been an issue increasingly on the agenda in society's concerns and discussions. Although such violence is not a contemporary phenomenon10, the visibility of this problem has a recent character, given that only in the last 50 years has the seriousness and severity of situations of violence suffered by women been highlighted15.

Inequality of power in relations seems to be a central issue in the phenomenon. Oppression has been presented as a way of exercising patriarchal power and, at the same time, perpetuating the inequities expressed in unequal gender relations10. Thus, women experience relationships based on aggressive behaviors that culminate in various types of violence, including sexual violence16. This, in turn, turns against the victim's sexuality, through coercion practiced by anyone, regardless of their relationship and in any scenario17. It manifests itself, in its multiple forms, as in the attempt to obtain a sexual act, unwanted sexual comments or advances or acts directed at sex trafficking4.

Faced with this problem, efforts to confront SV have culminated in the development of strategies that ensure women's rights. These have called on society to re-signify constructed historical and cultural contexts, in which they circumscribe perpetuation and end gender inequality17. However, although the advances to be faced are acknowledged, the approach to the theme proves to be imprecise in training spaces, for example, in the undergraduate nursing course, in which the gap between social issues and curricular matrices is observed1.

It is observed that the discussion is based on clinical care, based on the health-disease-conduct performance model for the diagnosis and treatment of STIs. This provides the opportunity for professionals to adopt protocols used in the prophylaxis of infections and have subsidies to provide accurate care to cases of violence17. Despite being important in the attention to SV cases, it propagates fragmented behaviors, restricting action to solve the problem and the victim's needs1. This attests to the inefficient inclusion in training, as the understanding of violence demands processes of acquisition of differentiated knowledge, which resort to the socio-political dimension11.

Nevertheless, this theme has gradually received more and more attention in health education spaces. Different disciplines have developed projects and interventions with a focus on violence, including, as can be seen in other university institutions18. As it is considered a social, complex and multi-causal phenomenon that affects individuals, families, communities and society, recognize that overcoming requires the involvement of different segments, requiring different views and different modalities in this area19.

It is evident the inclusion in a transversal way in the curricular content as an integrating mechanism. It is a fact that cross-cutting themes have been incorporated into curriculum policy as a proposal to overcome the fragmentation of knowledge, bearing in mind that in contemporary society, knowledge must have a new conFiguration11. In the last few years, the importance given to the question of transversality has been established in the minimum curriculum of undergraduate courses. It is believed that the idea presents itself as a bet for change in Higher Education20.

However, the existence of the theme in the matrices does not mean that the students will be able to face the problem. It is necessary to fill the gap in training to encourage students to develop criticality. Thus, active methodologies have been used, which make classes more dynamic and less theoretical, interdisciplinary and dialogical10. These problematize challenges so that students can build knowledge and live experiences, promoting a closer relationship between the university and the job market21.

Regarding the discussion on gender violence, it is still necessary to integrate the scientific interfaces into the study, to develop teaching strategies that deal with the expressions of violence. It is identified among the participants that the approach to the theme in undergraduate courses is temporary and nonspecific. Thus, health professionals leave universities unprepared to face implicit demands, which are not declared by patients22. Therefore, recognize that little has been qualified for dealing with sensitive issues and with a strong moral burden, which demand to deal with complex issues.

However, although the theoretical contents addressed in the classroom spaces are incipient, it is identified that the internships have offered students contact with the theme. This is mandatory in the last two semesters, in general and special hospitals, outpatient clinics and basic network. It is characterized as a scenario for internalizing real situations and carrying out practices learned during the undergraduate course23. About SV, it enables the acquisition of knowledge and the adoption of attitudes towards cases during the profession. It is considered that this activity is not a plausible excuse for the deficiency of the theme in the curriculum, however, it shows itself as a promising alternative to fill this gap in training.

In addition, the consolidation of groups in the HEI was evidenced with the involvement of students and teachers to discuss the topic. It is true that extracurricular activities have revealed themselves as one of the guidelines of teaching policies and space for the construction of knowledge. The formation of research groups presents itself as an important strategy to engage students in coping with the problem, considering that they have a closer approach as an act of investigating and critical reflection in face of possible problems. solutions24.

This is added to the development of the extension that makes it possible for the student to encounter real situations by integrating the university with society. This identifies the demands and promotes the exchange, generating benefits for both sides as a two-way street, with traffic guaranteed to the academic community, which will find, in society, the opportunity to build knowledge. It also stands out for its interdisciplinary approach that promotes interaction between universities and other sectors, enabling plural and heterogeneous knowledge to intertwine and dialogue among the production of meanings25.

However, the framework provided does not yet include aspects for the understanding of SV related to gender. There is a predominance of the clinical-biological aspect, embedded in the curricular content of the course, implying the encounter of characteristics recommended in the way of producing health and does not adequately respond to the complexity of violence26, which suggests, implicitly or explicitly, the importance of promoting the discussion in the fields of health education.

The inclusion of this subject in the curricular contents, presents itself as a promising alternative when contributing to the training of professionals. It is believed that this implies facing issues of the social and health reality and enables the provision of quality services from an integral, emancipatory and intersectoral point of view1, especially in view of the current social reality, which imposes the need to foster thematic in the fields of health education, especially in the undergraduate nursing course.

Therefore, it appears that the students themselves show an interest in discussing the topic, which may be related to an intrinsic need to learn to be able, in the future, to relate theoretical and practical knowledge in care. A study developed at the Nursing Department of a Federal University located in the Northeast of Brazil, showed that in all periods, the highest scores found were in Intrinsic Motivation for Knowledge and Intrinsic Motivation for Achievement27.

The teacher's skills are also identified based on professional experiences as opportune to relate theory and practice and reproduce the social reality in the classroom. In the case of SV against women, it is assumed that experiences and skills can enable the teacher to contribute to the construction of knowledge. However, it is emphasized that just knowing the technique is not enough to teach, it is necessary to master the pedagogical area10, which makes it important to avoid the spontaneity of professional skills for teaching practice still present in the academy.

It appears that the discussion has gained more prominence when students manage to express different cases of violence in collective. This situation looks at personal and family experiences and brings concerns about the phenomenon to the stage. However, it is known that the topic in question has still been recognized by peers as a contest and, at times, debates have given rise to negative emotions, implying that teachers adopt as the only and best option to curtail dialogues in the classroom. This, on the one hand, repressing internal and/or external conflicts and ensuring the emotional health of the students, but, on the other hand, making the discussion about SV silent1.

In addition, it is evident that the teacher is unprepared to mediate discussions in the classroom due to the insufficiency of knowledge about aspects that permeate the theme. In fact, if the teacher does not have a clear knowledge of the profession, he runs the risk of reducing his action to the mere reproduction of models learned in training. However, it is known that currently the role of socializing knowledge only by the teacher has lost its validity. The teacher is already distinguished as no longer the exclusive possessor of knowledge, but as one of the parties responsible for teaching and learning11.

Among the possibilities raised to promote the inclusion of the topic in Higher Education, the formation of exclusive disciplines on violence, health and gender stands out. A study developed at an HEI in Mozambique, showed the existence of disciplines on Health, Gender and Human Rights. These, in their menus, address issues related to violence, gender and human rights and their relationship with the health-disease process, in addition to guidelines, work and training28. Therefore, the dialogues on the theme at the University, allowing the demystification of the subject and the sharing of experiences11.

However, it is noteworthy that training is not restricted to the sum of knowledge added through mandatory subjects. It is emphasized that more and more ways of educating have been sought and rethought, following the transitions and needs of humanity11. In this way, the organization of scientific events is evidenced as an important strategy for the f formation of this theme, which is still little explored. This activity brought together groups interested in sharing and obtaining knowledge, allowing the exchange of experiences, updating on recent aspects and developing goals for the future29.

The inclusion of the theme in graduation through experience in teaching-service-community is also a strategy to provide a better understanding of the phenomenon. This favors an approach to the health and living conditions of women, enabling the identification of their needs and the realization of care plans. A study carried out in Higher Education schools in the United Kingdom, showed that the involvement of students with the problem during professional training, from visits to reference services in care for women victims of violence, is of fundamental importance for the preparation of the future. health professional in response to cases of SV30.

It should be noted that the limitations of the study are linked to the methodological aspects adopted that do not allow the generalization of information, however, it is recognized that the findings obtained may be like that found in other scenarios, considering the norms in Brazilian higher education, as well as the basis of gender violence in the country.

It is also believed that this study presents important elements to give greater visibility to the problem in the production of scientific knowledge and to open new horizons for the discussion on the theme in academic spaces. In addition, the findings support new debates at an opportune time when the reorientation of curricular guidelines for health courses in the country is discussed.

CONCLUSIONS

The study allowed us to conclude that SV against women presents itself as a remote social problem, with a characteristic of the condition imposed on women in relation to men of subjection. This has gained more visibility in the social scenario from the development of policies that ensure the right to health to the detriment of women's particularities.

However, in the training spaces of the undergraduate nursing course, the existence of a close relationship for its inclusion is still identified. The approach is revealed in a superficial and punctual way between the walls of the HEI, through unspecified disciplines and extracurricular activities, without deepening the issues that become important for understanding and solving the problem.

In recognition of the seriousness of the problem present in contemporary society and of the university's responsibility and social commitment, the importance of including this theme during professional training is verified, through academic activities that make it possible to integrate and expand the discussion in internal spaces as also external to the HEI.

REFERENCIAS

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Received: December 15, 2020; Accepted: March 03, 2021

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