How is Violence Themed in Nursing Education? Curricular Components in Northeastern Brazil

Abstract

It aims to identify how the phenomenon of violence is themed in the curricular components of undergraduate nursing courses of public and private higher education institutions in Northeastern of Brazil.

This is a descriptive and exploratory study, with documentary design and qualitative approach, based on the identification of the terms violence/aggression/abuse/aggressive/abusive in discipline menus available online from higher education institutions in northeastern Brazil. The data were organized and processed by the IraMuTeQ software and analyzed in the light of the relevant literature.

In total, 412 nursing graduate institutions were found, in which 49 had documents available online, and, of these, 21 had the term violence. The processing of the syllabuses in the program resulted in significant use (79.37%) originating from the Descending Hierarchical Classification, seven classes that reveal the highlight of the approach of violence directed at the female public and in this context, the approach to violence against women was associated with sexual and reproductive aspects, and in a secondary way, it integrated the perspective of female vulnerabilities, power relations, consequences of violence and nursing care to cope with the phenomenon. Violence against children and adolescents and the discussion of violence in the contexts of collective health and health promotion were also approached in a less intense way.

There was a predominance of the approach to violence aimed at women’s health, under a biological approach, with a deficit in the transversality of the contents. However, it is important to highlight potentialities associated with the approach and teaching of contents that stimulate the critical thinking of the student before female vulnerabilities and power relations between the sexes, which can contribute to the reformulation and reorientation of nursing curricula, restraining deficits, and optimizing the potentialities.

Keywords

violence nurses and nurses higher education curriculum qualitative research

Violence is a public health problem and is characterized as any act or omission that results in or will result in physical, mental, and/or lethal harm (Brazil, 2016). According to the World Health Organization (WHO), violence is divided into three major groups, namely (i) self-inflicted violence (suicide, suicide attempt, and self-abuse), (ii) interpersonal violence (community violence and family/domestic violence), and (iii) collective violence (violent acts that occur in the macrosocial, political, and economic spheres and characterize the domination of groups and the State) (Krug et al., 2002).

Among the groups listed above, interpersonal violence stands out, which is presented, according to Carmo (2015), especially related to vulnerable groups, such as women, Lesbian, Gay, Bisexual, Transvestite and Transsexual populations, children, adolescents, people with disabilities, traditional people, indigenous peoples and afrodescendants. Polidoro and Canavese (2018), highlight that the vulnerabilities of such groups to violence are associated with sexism, racism, xenophobia, homophobia, religious intolerance, generational conflict, street situation and/or capacitive, among others.

Regarding the epidemiological aspect in the world, 464,000 people were victims of homicide in 2017. With regard to Brazil, it has the second highest homicide rate in South America (30.5/100,000 inhabitants) (UN, 2019). Thus, the lethal repercussion of violence is present in Brazil in ascendancy, since, in 2016, there were 62,517 homicides in the country and, in 2017, 65,602 cases of the same crime (Cerqueira et al., 2019).

Regionally, the Brazilian Northeast stands out, as this region has the highest rate of lethal violence (FBSP, 2019). This reality results, in part, from the historicity and culture of the northeastern people, who are immersed in an arid and violent region, which favors the generation of conflicts and often incites violent behaviors in a reactive way to the suffering experienced; under strong influence, both of colonialism, a political-social practice that reinforces stereotypes of power in dominant groups, and by social inequalities, in which the Northeast is inserted, impacting on economic precariousness and struggles for subsistence (Lira, 2018; Rodrigues et al., 2017).

From the above, it reflects on the consequences that violence has on the health of the population affected by it. The studies of Netto et al. (2014), Damasceno and Zanello (2018), Cordeiro et al. (2017), Albuquerque and Parente (2018), and Rangel et al. (2018) argue that the impact of violence is not limited to physical and/or lethal repercussions, but also concerns the chronic consequences on the mental, sexual, and reproductive dimensions of the affected populations.

Furthermore, expenses on health services resulting from the consequences of violence is also high, as Cerqueira et al. (2019) reveal, about Brazil having spent nine billion of its Gross Domestic Product (GDP) on health services to assist victims of violence in 2003. In view of the impact of violence on health and the high expenses with health services, it is important to implement coping measures that reduce vulnerabilities, chronic suffering and deaths resulting from this grievance (Brazil, 2016).

Thus, coping with violence, through its prevention, early identification, and treatment, must occur through practices and services that minimize it, for which the health sector has great relevance, because it will enable the implementation of specific policies that seek to intervene in this event (Mascarenhas et al., 2016). However, considering that such actions are not limited only to the treatment of physical injuries, but include actions to identify, monitor, notify cases, and monitor victims, it is extremely important that health professionals are qualified and sensitive to recognize the signs of violence and manage the people to be assisted (Amarijo et al., 2020; Brazil, 2016).

Among the prominent health professionals who work in health services and in the network of coping with violence, the nurse is evidenced. According to Figueiroa et al. (2017), the nurse has training based on a humanistic and generalist science that requires professionals endowed with knowledge, skills, and attitudes to cover the human being in their biopsychosocial, spiritual, and cultural aspects. Thus, nurses can provide comprehensive care to the human being in the face of the determinants that imply in the health-disease-care process, among them, violence (Figueiroa et al., 2017).

Faced with the phenomenon of violence, nurses carry out actions to prevent, identify, guide, and assist victims, families, and the community. According to Aquino et al. (2014), the main instruments used in the nursing consultation to identify these cases is the nursing process. Moreover, the reception and the creation of bonds through the professional-patient relationship are essential to effect adequate care for the person in a situation of violence.

It is also noteworthy the responsibility of nurses through the legal aspect and moral conscience in the face of the situation of violence. However, even if the recognition of people in situations of violence and their action in the fight against harm are part of their professional practice, they are still not familiar with the recognition and measures to be taken in the face of the phenomenon. Thus, it is inferable that these difficulties are reflections of a superficial approach on the subject in undergraduate nursing courses, which contributes to the unsatisfactory reception of victims and inability of notifications of violence cases (Marinho & Gonçalves, 2016).

This superficial approach is pointed out by Martins et al. (2017), who conducted a research with nursing curricula and identified that violence is not worked throughout the undergraduate course, but only in some disciplines that do not contemplate alone, the entire complexity of the approach to the phenomenon. Study by Rigol-Cuadra et al. (2015), conducted with 112 Nursing students about knowledge, beliefs, and practice through intimate partner violence, pointed out that students are unaware of the characteristics of abuse, guidelines, screening, and screening issues; they do not identify their professional role in front of the victim and have the belief that violence is not associated with the health sector.

Another study conducted based on curriculum analysis and also with interviews with undergraduate nursing students, under the focus of sexual violence against children and adolescents, identified that none of the disciplines in the curriculum presented the approach of this type of violence, that discussions on the subject were incipient, and that the students did not demonstrate scientific property to act through cases of sexual violence, attributing to other professionals the responsibility for the management of victims (Fujita & Landini, 2012).

Study by Zanatta et al. (2018), conducted with 19 nursing graduate educators from two Higher Education Institutions (HEIs) in Santa Catarina (Brazil), revealed that the theme violence is worked in an elementary way, with superficial critical reflection on the practice, reflecting the invisibility of the approach of the theme in the pedagogical projects of the course (PPCs). Thus, nurses have insufficient preparation for the care of victims of violence (Martins et al., 2017).

In this context, according to the National Policy for the Reduction of Morbidity and Mortality from Accidents and Violence in Brazil, HEIs should participate more presently in the training of professionals, training them for the management of emergency situations and care for victims of violence, as well as for the development of preventive measures; contemplating, to this end, not only clinical and managerial aspects, but the psychosocial approach to the disease (Brazil, 2002).

According to Funghetto (2015), the National Curriculum Guidelines point to the need for a generalist, humanist, critical and reflexive training of professionals in the various health areas. Oliveira Silva et al. (2013) defines the profile of the student with a view to the ability to act with a sense of responsibility, ensuring and preserving the basic human rights of individuals; which is indispensable for action in the face of violence.

However, although there are guiding documents that guide pedagogical practice in undergraduate nursing courses, these guidelines do not always contemplate all aspects essential to nursing education. Therefore, it should be mentioned that universities approach the theme of violence in a timely manner, training health professionals with weaknesses for the identification and care of victims (Silva et al., 2016).

In view of the above, it was considered relevant to know how the approach of violence in nursing graduate courses is themed, through the possibility of contributing with evidence to address difficulties or optimize already effective aspects. Thus, this study aims to identify how violence is themed in the curricular components of undergraduate nursing courses of Public and Private HEIs in Northeastern of Brazil.

Method

This is a descriptive and exploratory study, with documentary design and qualitative approach. The search was conducted from March to May 2020, starting with the survey of HEIs with nursing graduation in the Northeast region, through access to the e-MEC website, which is an electronic system that enables the monitoring of the process of regulation of HEIs in Brazil.

According to the e-MEC, Brazil has 1,472 HEIs (565 in the Southeast; 412 in the Northeast; 197 in the South; 164 in the Midwest region and 134 in the North region) with undergraduate Nursing courses. However, this amount encompasses all campuses of the same HEI. When filtering the campuses repeated by State and between states, in each region, there is the following quantitative: 728 starting with the survey of HEIs with nursing graduation in the Northeast region, being distributed in the following: Southeast Region—281, Northeast Region—158, South Region—123, Midwest Region—98, and North Region—68.

The search in the Northeast Region is justified not only because it is the second region with the highest number of HEIs with a nursing degree (second only to the Southeast), including 21.7% of nursing courses in Brazil (e-MEC, 2020); but mainly, because it is the Brazilian region with higher rates of lethal violence, besides having a cultural history immersed in violence and constituting itself as a region with higher rates of educational and income inequality, which leads to greater social vulnerability and, thus, greater risk for the occurrence of the grievance (FBSP, 2019; Lira, 2018; Rodrigues et al., 2017).

Participants and Criteria

After identifying the number of HEIs, there was the search for the pedagogical material available online on the institutions’ website. The pedagogical projects of the courses or political pedagogical projects available were accessed and those who contained the term “violence,” “aggression,” “abuse,” “aggressive,” and “abusive” in the menus were selected and read. The syllabuses were chosen for qualitative analysis because they include detailed information on the teaching of the theme.

For the inclusion of menus, the following criteria were used: (i) be available online, (ii) in the public domain, and (iii) to have the following associated or isolated terms: violence, aggression, abuse, aggressive, and abusive. The following were excluded: (i) incomplete documents, (ii) documents of courses not yet started, (iii) documents whose words mentioned above were only introductory to the document, and there was no clear description of how this theme was worked in teaching, and (iv) when the word identified referred to a context other than that of violence (such as the term abuse related to substance abuse).

It is worth noticing that since the beginning of the COVID-19 pandemic, in March 2020, the activities of the HEIs in Brazil were suspended, which made it impossible to make available pedagogical material/menus not available online, even if before request by e-mail, since the documents/materials of the courses remain in the institution.

Of the 158 HEIs that are part of the nursing course, 49 provided pedagogical projects of the courses, political pedagogical projects and/or mentoring on the institutional site, and only 37 had complete documents and of this total, 21 menus presented the term violence, aggression, abuse, aggressive and/or abusive described in some discipline.

Data Collection

For data collection, an adapted instrument developed by Lima (2018), previously adopted in a similar research, which addressed the teaching of gender and sexuality in undergraduate nursing courses, was used, having proved relevant for allowing the systematization of data collection and for having comprehensive variables, which are as follows: State of the HEIs, number of campuses, teaching modality (in-person or distance), number of places made available by the HEIs per year, course load, administrative category (public or private), characteristic of subjects that contained the terms “violence,” “aggression,” “abuse,” “aggressive,” “abusive” (mandatory or optional), hour load and discipline modality (theoretical or theoretical and practical). The aforementioned terms identified directed to the discipline in which the theme was addressed, being read in full to extract the contents related to this phenomenon.

Data Organization and Analysis

The contents were organized in the Libre Office Writer program, version 6.4, in which the material was prepared through readings, corrections and decoding of the fixed variable. The encoding exposed concerns the number of HEIs and the State where the searched terms were found, as can be mentioned *IES_AL_01; *IES_BA_02…; *IES_SE_21. It is noteworthy that the State of Piauí did not present any syllabus addressing the theme violence.

The data were submitted to processing in the Program Interface of R pour L Analyses Multidimensionals of Textes L of Questionnaires (IraMuTeQ), version 0.7 alphas, which allows to discover the essential information present in a text, through textual analysis and statistics. Thus, even though the quantitative analysis of textual data is present, the software does not cease to consider the quality of the phenomenon studied, and still generates criteria from the material itself for the consideration of it as an indicator of a phenomenon of scientific interest (Camargo & Justo, 2013).

For this study, we used the analysis of the textual corpus of the menus, through the Descending Hierarchical Classification; it generates Segments of Texts (parts of the analyzed texts) from the textual corpus (set of texts analyzed) and performs the crossing of them, identifying in this way, classes of words that present similar vocabulary to each other, that is, divide the textual corpus into classes, grouping the words of strong association and presenting the percentage of representation in the corpus studied (Camargo & Justo, 2013).

For the creation of a dictionary of words, the program uses the chi-square test (χ²), which reveals the associative strength between words and their respective class. This associative force is analyzed when the test is greater than 3.84, representing p < .0001. The smallest chi-square represents a smaller relationship between the variables, that is, it represents that the analyzed word is farther from the others, which graphically (in the dendrogram) presents a word smaller than the others (Lahlou, 2012; Oltramari & Camargo, 2010). The analysis of the findings was performed in the light of the relevant literature on interpersonal violence.

Considering that there was no involvement of human beings, this research did not require approval by the Research Ethics Committee and the National Research Ethics Commission (CONEP).

Results

The search returned 412 HEIs, of which 54 had pedagogical projects of the courses, or political pedagogical projects online, and of these, 37 had a syllabus list. Regarding the presence of the terms “violence,” “aggression,” “abuse,” “aggressive,” and “abusive” in the disciplines, this was identified in 25 documents, but in four, the presence of the term was not related to its approach, thus excluding such syllabus.

Regarding the characterization of the 21 HEIs with syllabuses selected, 14 had only one campus; three had two campuses; two had three campuses; one with four campuses; and another with 32 campuses with a nursing graduate course. Table 1 shows specifications on nursing courses, according to each HEIs in the Northeast, Brazil.

Table 1.

Profile of the Nursing Graduate Courses of the HEIs Whose Syllabuses Approaching Violence Were Available (e-MEC, Northeast, Brazil, 2020).

State	No. of Campuses	In-person	DL	Average Places	Average Course Load	Public Category	Private Category
Alagoas	01	01	00	040.0	4578.0	01	00
Bahia	23	08	15	056.8	4078.1	04	19
Ceará	11	06	05	107.4	4224.0	01	10
Maranhão	01	00	01	040.0	4000.0	00	01
Paraíba	03	01	02	047.3	4000.0	01	01
Pernambuco	09	06	03	063.8	3241.8	05	04
Rio Grande do Norte	05	05	00	063.6	4729.0	04	01
Sergipe	02	01	01	115.0	4000.0	01	02
Total	55	28	27	533.9	3.2850.9	17	38

Source: Syllabuses and information available by e-MEC.

Note. DL = Distance Learning.

Regarding the information obtained, the nursing course occurs predominantly as in-person on 28 campuses. The HEIs have an average of places ranging from 40 to 115 places per year, with a preponderance of 4000 hours of course load per campus. As for the administrative category, most campuses are private HEIs (n = 38).

Concerning the subjects whose syllabuses contain words “violence,” “aggression,” “abuse,” “aggressive,” “abusive,” Table 2 addresses their characterization.

Table 2.

Profile of Subjects Addressing Violence (e-MEC, Northeast, Brazil, 2020).

State	No. of Mandatory Subjects	No. of Optative Subjects	Specific Subject	Mean Hour Load	Theoretical Modality	Theoretical and Practical Modality
Alagoas	03	00	00	100.0	00	03
Bahia	32	05	01	067.8	05	32
Ceará	17	00	00	099.1	00	17
Maranhão	07	00	00	100.0	00	07
Paraíba	09	00	00	091.1	00	09
Pernambuco	21	00	00	122.5	01	20
Rio Grande do Norte	02	00	00	135.0	00	02
Sergipe	08	00	00	431.0	00	08
Total	99	05	01	1146.5	06	98

Source: Syllabuses of the northeastern nursing graduate courses.

The states above present HEIs in nursing with syllabuses with more than one subject addressing violence, with a preponderance of 99 mandatory subjects. Moreover, only one subject is specific to violence and 94.2% of the subjects are theoretical and practical.

Analysis of the Textual Corpus

The textual corpus (set of texts of the menus analyzed) resulting from the processing by the IraMuTeQ software consisted of 21 texts (which equated to 21 menus), separated into 63 Text Segments (separation of the textual corpus by the software), of which 50 were used (79.37%). There were 2004 occurrences (words, shapes, and terms), with 424 active forms (adjectives, nouns, verbs, prepositions) and 25 supplementary forms (auxiliary verbs). The analyzed content was categorized into seven classes through Descending Hierarchical Classification.

In the dendrogram (Figure 1), the textual corpus is divided into seven classes grouped in subcorpus according to the relationship between them, as follows: (i) subcorpus A, branched in classes 4 and 5, linked to subcorpus B; (ii) subcorpus B, whose branches comprise class 7, which relates directly to class 6, which in turn branches out into classes 2 and 3; and (iii) subcorpus C, with class 1 independent, directly linked to the other subcorpus. It is observed, through Figure 1, that the branches and links of the subcorpus express the connection between the classes, which even bringing the approach of different subjects, have a common essence, interpersonal violence. The words “larger” represent the most representative words in the text, those that generated chi-square (χ²) larger.

Figure 1.

Source. Data of the syllabuses processed by IraMuTeQ.

The teaching of violence in the analyzed syllabuses is predominantly directed to women, both in specific categories, bringing directions of the nurse’s performance toward this public, as in a capillary way in other subjects. This perception was obtained by analyzing the dendrogram generated, as well as from the menus (see in appendages).

In class 01, entitled: female vulnerability and violence, it can be seen from the analysis of the commentaries, the association between the approach to violence against women and female vulnerabilities. This class comprises 12% of the corpus analyzed, being composed of significant words (p < .0001) public (χ² = 31.88) and vulnerability (χ² = 16.34), which, associated with others with decreasing significance level (reproductive, right, sexual, race, female, woman, gender), highlight that female vulnerabilities are associated with gender issues, imbricated to sexual and reproductive rights and issues of race that should be considered in policies to combat violence.

In class 2, entitled: Coping with violence in the child-adolescent perspective the approach to violence appears associated with children and adolescents, being contemplated by 14% of the total corpus analyzed and composed of significant words (p < .0001) as child (χ² = 42.73) and adolescent (χ² = 37.08). Below, it is exposed how the approach of this theme occurs.

The syllabuses approach aspects related to child-adolescent violence from its conceptualization, typology, and risk factors, as well as the description of the performance of the future nurse professional through assistance of cases of victimization in children and adolescents and the adoption of protective measures and referrals to protection agencies for this public. Another important highlight is the approach of this content associated with domestic and intrafamily violence, so that its teaching is close to the approach of violence against women. Furthermore, there is a trend to discursive approach through case studies to envision comprehensive victim care.

Regarding class 3, entitled: Violence under the collective health perspective, violence is approached from the perspective of collective health actions, envisioning the repercussions of the phenomenon in health services, demonstrating the need for health care through work in networks and health surveillance actions. It comprises 14% of the corpus, composed of the significant word (p < .0001) situation (χ²=15.74).

This class shows that the syllabuses integrate violence not directed to specific audiences and contexts, but dialoguing about working in health care networks, the mobilization of society to support the victim and the support of the humanization policy, which converges with the identification of risks and vulnerabilities. These points are necessary in view of the repercussions of violence within health services.

Class 4, entitled: Women’s sexual and reproductive health and interface with violence, it represents 18% of the total corpus, with the significant word (p < .0001) sexuality (χ² = 25.31), in which it is perceived the reconciliation of the approach to violence with the explanation of female reproduction and sexuality.

The approach presented in this class suggests the combination of the social problem of violence with the biological aspects of women’s health, though less clearly, since the emphasis is on issues related to their sexual and reproductive health. Moreover, violence is not addressed transversally with women’s health, but by punctual exposures, which can configure a fragility, due to the secondaryization of an emerging problem, which must be worked on its peculiarities in depth.

Corroborating with the previous class, class 05, entitled: Nurses’ work before violence against women, it comprises 14% of the textual corpus, consisting of the significant words (p < .0001) assistance (χ² = 37.08) and nursing (χ² = 15.74). This class identifies the specific approach of violence against women, its manifestations, and nursing actions for care and coping process.

This class is interrelated to classes 1 and 4, addressing women’s victimization. In this, we can see the approach of specific points of the content worked, such as the perspective of gender and patriarchy, characteristics and concepts of violence and nursing care through the phenomenon. Furthermore, specific violence, such as interpersonal violence between men and sexual violence against women, stands out.

Class 6, entitled: Violence and health promotion, reveals that the HEIs have also addressed violence under the focus of health promotion. Characterized with 14% of the total corpus, the word “accident” manifests significance (χ² = 34.77), observing that the HEIs have used the reference of external causes to approach violence, from the perspective of health promotion, prevention, and protection at the various care levels.

In addition to the focus on health promotion, prevention, and protection actions, with the approach of educational actions, social mobilization, and integral actions with the support of guidelines and norms; this class also addresses specific forms of violence, such as obstetric violence, bullying, child labor and violence against the elderly, with emphasis on the recognition of groups at risk of victimization. The results suggest that the syllabuses favor an expanded approach to violence, not limited to the consequences of the phenomenon, but considering the proactivity in educational actions for its prevention.

Lastly, class 7, entitled: Relations of power and violence, it comprises 14% of the total corpus with two representative words (p < .0001): relationship (χ² = 27.22) and nurse (χ² = 20.01). It is undertaken that this class shows that the nursing student must understand the power relationships that surround the practice of violence.

This class approaches gender relations, family relationships and political relationships in the conformation of the exercise of power as a form of domination and support to the practice of violence. Furthermore, it addresses two specific types of violence: perpetrated against women and urban violence. It is noteworthy that, although the syllabuses mention the social and cultural diversity, as well as the approach of tolerance/intolerance and inclusion/exclusion, the approach to violence against specific publics, of interest to these determinants, such as the Lesbian, Gay, Bisexual, Transvestite and Transsexual public, black population and supporters of less prevalent religions seems invisible.

Moreover, it was identified that the violence suffered and/or perpetrated by nurses was not addressed in the menus, which is considered a weakness, considering that the stressful environment of health units favors conflicts between patients and professionals. Furthermore, considering that the majority of nursing professionals are women, it is considered that the determinant of sexism makes these professionals vulnerable. Finally, the approach to violence perpetrated by nurses and nursing staff in general (including nursing technicians and assistants) against patients and/or other coworkers was also not identified, suggesting future studies to include such an audience.

Discussion

The responsibility of the health sector in the care of victims of violence has instilled a reorganization in the logic of care, requiring articulation between sectors and multidisciplinarity between teams (Minayo et al., 2018). To this end, there is need for discussions on violence in the training and qualification of health professionals (Minayo et al., 2018), among them, the nursing professional.

The nurse is, generally the first professional to approach the victim, using relational technologies for the bond, which optimizes the process of identification and management of the situation. In view of the training of this professional, it is essential to approach and teach the theme violence, aiming to qualify him/her to cope with it (Silva & Ribeiro, 2020), and, therefore, it is considered that the transparency of formative processes is indispensable for the visualization to society of the competencies and attributions worked with them, in order to meet the social demands in health.

In this sense, it is imperative that the HEIs publish, at their online channels, documents and pedagogical materials, a reality mostly not identified by this study, in which a low number of Educational Institutions with available materials stood out, although normative guidelines reinforce the opposite. In Brazil, Decree n. 9,235 of December 25, 2017, provides for the exercise of the functions of regulation, supervision, and evaluation of HEIs, and in its sole paragraph, establishes that the HEIs is responsible for disclosing its institutional acts, courses and pedagogical documents to students, present in Art. 47 of Law no. 9394 of 1996 (Brazil, 2017).

However, it is worth noting that low publicization has had repercussions on a limited access to menus, and this is a limitation identified in this study, it is worth reinforcing that because it is a study with a qualitative approach, its construction should consider not only the quantity, but the scope with which the study data source (in this case, the menus) present the multiple dimensions of the investigated phenomenon. Thus, this type of approach is less severely concerned with generalization, and, more instance, with the deepening, scope, and diversity in the process of understanding the object of study (Minayo, 2017). It is believed that the study allowed an understanding of how the approach to violence occurs in HEIs.

Furthermore, from the understanding of the phenomenon of violence through documents originated in this research, discussions can be supported to support the need for field research with students and nursing professors, which allow deepening knowledge about identified gaps.

It is also believed that a study is valid because it allows the deepening of the debate on the vulnerabilities associated with interpersonal violence that the population of the Northeast region presents, both for its cultural history marked by violence and for the high rates of social inequality (Lira, 2018; Rodrigues et al., 2017).

Although, in view of this situation, based on the analysis of the syllabuses of nursing graduate courses before the teaching of this theme in the Brazilian Northeast, the precepts of the National Policy for the Reduction of Morbidity and Mortality from Accidents and Violence are considered, especially when violence against women stands out, alluding to this public, presenting great victimization (Brazil, 2001). However, although the policy highlights the focus of social determinants of health in the increase of morbidity and mortality rates due to external causes, the approach of this problem, such as violence against women revealed in syllabuses, is still based on the biological perspective, with origin and repercussions on sexual and reproductive aspects and rights.

It is noteworthy that this biological model is the result of biomedical hegemony still present today, which centralizes health care in the disease, the professional and his/her expertise to promote healing, in most cases, dissociated from the social aspects determinant in health (Esmeraldo et al., 2017) reflecting, in the results of this study, through the approach that highlights the performance and practical assistance to the victims, suggesting that the teaching on violence in Nursing translates into a technicist panoramic.

Another point that can justify the greater focus of violence against women occurs because this public is the one with the highest proportion in health services, due to gender stereotypes and sexual division of work, which attributes to women the duty of caregiver, instilling concerns about their health and of their family members, strengthening female self-care as a compensatory form to their structurally established fragility due to their sexual and reproductive attributes (Botton et al., 2017); this thought, still reinforced in the health academic field, reaffirms the main interventions directed to this public, of a sexual and reproductive character, even before the occurrence of victimization.

In fact, interventions under the sexual and reproductive processes of women have always been allied to their domination, under the gender approach, through the objectification of their bodies at the social and sanitary level, not only by aesthetic patterns and sexual behaviors, but by body discipline due to weaknesses built under the pretext of illnesses linked to reproduction (Santos & Germano, 2020) and, in this context, the process of medicalization and pathologization of female bodies is inserted in function of reproductive activity, in which motherhood and, especially, childbirth emerge as a crucial moment, in which the performance in health affects the lives and bodies of women (Silva, 2018).

Historically, female bodies are manipulated by health professionals, essentially from the perspective of medicalization, in which natural to pathological processes are shaped, leading to the loss of female autonomy in relation to their body (Rodriguez & Gallardo, 2017), which is reinforced by the biological approach of syllabuses.

In addition to the manipulation of female bodies in the health care scenario, due to gender inequalities, patriarchal precepts that dictate dominating men and submissive women normalize violence against women (Brown et al., 2017), a position reinforced in the Northeast Region, which possibly raises their prominence as the greatest victim in health services before the problem.

Thus, the northeastern context sheds light on the need for an expanded view of violence against women in health training processes to denaturalize the power relations of the culture of this region, since this environment has traditionally strengthened and further reinforces, among generations, patriarchy, through the culture of overestimating marriage as the only tool for women to obtain dignity, perpetuating the idea of submission of this to their partner, even in situations that cause suffering, such as those of violence experienced (Azevedo & Dutra, 2019). Furthermore, throughout history, the Northeast has not been a promising environment for women’s schooling, restricting them to the home, reinforcing their submission and the occurrence of violence (Lira, 2018).

In addition to the perspective of social construction of gender as a factor that implies a greater approach to the female public, nursing education before this public is also guided by the National Policy of Integral Women’s Health Care, which reinforces the motherhood-centered biomedical approach; but expands its scope to other aspects, such as domestic and sexual violence, aiming to organize and articulate networks of care for women in situations of violence with actions to prevent sexually transmitted diseases and promote preventive actions in relation to the problem (Brasil, 2004).

In this sense, the syllabuses advance, not only because they contemplate the objectives of the National Policy of Integral Women’s Health Care concerning the approach of violence, but also because they provide discussions and reflections from the perspective of humanization, recognition of female vulnerabilities and power relations between the sexes, typologies and consequences of violence and compulsory notification, which together allow expanding the intersection between violence and collective health.

There is a concern of the curricula analyzed with the integrality of care to victimized women, mentioning and teaching protocols and actions to be applied by nurses in the various care levels for women in situations of violence, as well as articulation of their performance with social support and protection services, which is imperative in health education, considering that professionals still present difficulties related to the articulation of points of the care network to women victims of this problem (Visentin et al., 2015).

Moreover, it is essential, in health training processes, to approach nurses’ actions toward the victim of violence, which should address the technical aspect of care for physical injuries; management for the referral of examinations and execution of institutional and mainly preventive protocols, with actions aimed both to avoid new problems, as well as to promote the rupture of women from the abusive cycle, considering the creation of a bond with women to perform comprehensive care based on their unique biographical situation (Cortes & Padoin, 2016). With these actions, it is perceived that, in general, the syllabuses reinforce nurses’ role in recognizing and coping with violence against women.

Furthermore, the approach and incentive to health education actions in the syllabuses, indispensable in the prevention of violence against women. The context of health promotion is something expected in nursing curricula, since this profession is associated with the process of empowerment of the individual for self-care. For this, health education is an important professional-patient interaction technology (Figueira et al., 2018).

It is noteworthy that health education constitutes an action that should be performed through knowledge and recognition of the needs of the population, which can be reflected in the female vulnerabilities addressed in the syllabuses. Thus, the knowledge of women’s vulnerabilities is essential for nurses to value the subjective dimension of women victims of violence, once limiting the objective dimension fragments their actions, which become little problem-solving and hinder bond and embracement (Marques, 2017).

The bond and embracement are enhanced when health education is part of the National Humanization Policy in the analyzed syllabuses, considering that it envisions the use of soft technologies in care, essential for nurses to understand the motivations that lead women to remain in violent relationships (Visentin et al., 2015), which are directly associated with the manifestation of male power (Brown et al., 2017), which validates the approach of power relations in nursing teaching.

Power relations between the sexes, when associated with violence against women, are expressed throughout the syllabuses, anchored in gender as an analytical category to understand female vulnerabilities, which exposes women to greater risks of being abused (Brown et al., 2017). Power relations can also be observed through the repercussion of violence for women’s offspring. This can be justified, both by the position of fragility, socially attributed to women, which extends to children, by their easy domination; as well as the interconnection of women’s health with motherhood, resulting in reflections on the health of children and adolescents (Almeida, 2014; Botton et al., 2017). Furthermore, there is a generational influence, in which women who witnessed violence against their parents (as children and adolescents) tend to reinforce their submission to men and remain in abusive cycles; moreover, conflicting environments between parents become violent to children (Paixão et al., 2015).

In addition to women and children and adolescents, the nurse’s relevance to identify other groups vulnerable to violence stands out, according to structural and cultural characteristics, including the elderly person, punctually described in the syllabuses. Thus, nurses should provide greater attention to this public, especially when it comes to the being “old,” who is twice as likely to suffer manipulation and violence, by both age group as gender, which is reinforced in the study by Bolsoni et al. (2016) with 1,705 elderly people, in which elderly women were twice as likely to suffer violence.

Despite the strong influence of female vulnerabilities and power relations on the origin and ascendancy of violence, the profile of this phenomenon is presented only as the tip of the iceberg, due to the underreporting of cases in health services, resulting from the professional’s inability to complete forms or lack of sensitization to recognize from the most symbolic signs of violence (Kind et al., 2013), which justifies the insertion of compulsory notification in the approach and teaching of violence in the analyzed syllabuses.

It is noteworthy that both teaching about violence and its notification contribute to the generation of important data for the elaboration of actions and assertive public policies to cope with the phenomenon, as well as the dissemination of these data and the implementation of these policies corroborate the incentive to expanded health education in the context of violence (Lima & Deslandes, 2015). Thus, the unique action of health surveillance for the academic and care spheres stands out, training nurses able to develop actions for the prevention, early recognition and management of this complication.

Implications for practice

Despite operational limitations regarding the number of available menus, as well as the restriction of access to these documents in full due to the COVID-19 pandemic; and the limitations already presented in the results regarding the little approach of other publics vulnerable to violence in the material analyzed, it is possible to raise reflections on the importance of greater exposure of menus on the websites of educational institutions, favoring in this way, dissemination of formative processes to the population, so that professional training is aimed at meeting social demands and coping with injuries, such as violence.

In this sense, even though the study was conducted only in the Northeast region of Brazil, it is possible that its results reverse reflection and possible reformulation of national nursing curricula, which, according to the results obtained by the menus, they should restructure the approach to interpersonal violence in an expanded way, inserting the discussion for several audiences besides women and children and adolescents (most cited), also contributing to the insertion of clinical cases about violence, as well as to encouraging internships in referral centers for people in situations of violence.

Moreover, it is necessary that the approach to violence occurs in a transversal way throughout the undergraduate nursing program, not only in summing up to one class or one discipline. Thus, it would be possible to sensitize nurses to the understanding of interpersonal violence, from its most perceptible forms (physical and sexual violence) to the less perceptible ones (psychological, moral, and patrimonial violence), which would enhance the early identification and proper management of the person in a situation of violence. It is worth remembering that teaching about interpersonal violence should encourage the future nurse to focus their care on the person in situations of violence and their specificities.

Thus, it is possible that this study has implications for the following dimensions: (i) clinical practice of nurses, because relevant aspects are evidenced in the victim's approach, which may cause nurses to reflect on their important performance in this scenario; (ii) nursing and health education, as it highlights the need for reorientation of nursing curricula, which can also impact other health courses that have the same weaknesses; (iii) scientific, because it provides a documentary picture of the field investigated, which drives researchers to enter this field in search of investigating the living organisms that compose it (professors and nursing students); and (iv) social impact, because it brings the discussion of interpersonal violence as a subject still invisible within society and, thus, potentiates the denaturalization of the culture of violence.

Conclusion

The syllabuses analyzed allowed identifying that the focus given to the approach of violence in nurses’ training processes in Northeastern Brazil is directed to women, with a biological focus, through a preponderant association of violence with the reproductive and sexual aspects of this public. This approach can limit nursing care due to the deficit in the transversality of the contents and the overlap of a model that restricts care to biological objectivity.

Although this focus predominates in relation to the social perspective, it is identified that a discussion on social aspects was subtly inserted in the components, in which potentialities are perceived when relating the approach and teaching of contents that stimulate the critical thinking of nursing students before female vulnerabilities and power relations between the sexes, which provides the stimulus to humanized practice and awareness of health surveillance as assertive actions in coping with violence.

Although with important findings, this study presented limitations, which are related to the online and integral availability of pedagogical documents from all HEIs in the Northeast and the impossibility of making available via e-mail, once such materials are stored in institutions that are closed as a result of the COVID-19 pandemic. Nevertheless, the gaps and potentialities identified on the approach to violence can contribute to reflections on the need to reformulate curricula, which include the training of nurses with an expanded eye for this phenomenon. Thus, future studies should work from the perspective of other Brazilian regions, as well as associate documentary research with field researches in the HEIs.

Footnotes

Authors’ Note

Supplementary material referring to excerpts from the menus analyzed in this article is available online.

Declaration of Conflicting Interests

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Beatriz de Castro Magalhães

Caik Ferreira Silva

José Adelmo da Silva Filho

Antonio Germane Alves Pinto

Evanira Rodrigues Maia

Maria do Socorro Vieira Lopes

Grayce Alencar Albuquerque

Supplemental material

Authors Biographies

Beatriz de Castro Magalhães is a master’s student of nursing at the Regional University of Cariri and a member of the research group on sexuality, gender, sexual diversity, and inclusion. He currently conducts research related to nursing with an emphasis on cross-cutting themes such as violence against women and vulnerable populations, sexuality, and affective-sexual and gender diversity.

Caik Ferreira Silva is a master’s student of nursing at the Regional University of Cariri, a member of the research group on sexuality, gender, sexual diversity and inclusion, and conducts research associated with nursing with an emphasis on themes such as sexuality, affective-sexual and gender diversity, social inclusion, violence against women and the vulnerable, and accessibility of these health services.

José Adelmo da Silva Filho is a master in nursing, PhD student in nursing, and a member of the Clinical Research, Care and Health Management Group (GPCLIN). He is interested in the themes of studies related to mental health, collective health, light technologies, and related areas.

Antonio Germane Alves Pinto is a PhD in education (all at Ceara state University), a teacher of the undergraduate nursing course and of academic master of nursing (URCA), a teacher of professional master in health education (UECE), and a professor of the graduate program in family health—master and doctorate.

Evanira Rodrigues Maia is a PhD in nursing. He is currently an adjunct professor at the Federal University of Ceará and an adjunct professor at the Regional University of Cariri. He has experience in the field of nursing, with an emphasis on public health, acting mainly on the following themes: nursing, health education, epidemiology, family health, and health diagnosis.

Maria do Socorro Vieira Lopes is a doctorate in nursing, an associate teacher at the Regional University of Cariri (URCA), a professor of the postgraduate program in nursing/URCA, the professional master’s in family health, dean of student affairs at URCA, and works on the following themes: family health, collective health, health promotion and education, and environmental health.

Grayce Alencar Albuquerque is a doctorate in health sciences, a teacher of the academic master of nursing at the Regional University of Cariri (URCA), a professional master of Nursing Course at URCA, a coordinator of the observatory on violence and human rights of Cariri—URCA, and a leader of the research group on sexuality, gender, sexual diversity, and inclusion.

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