RESEARCH ARTICLES

Reporting of violence against children and adolescents: action of nurses in basic health units

Stella Minasi de Oliveira^I; Laura Coelho Passos Fatha^II; Veridiana Lopes da Rosa^III; Cassiana Duarte Ferreira^IV; Giovana Calcagno Gomes^V; Daiani Modernel Xavier^VI
INurse. Master's degree in Nursing. Professor of Nursing School at the Federal University of Rio Grande. Member of the Study and Research Group in Nursing and Child and Adolescent Health. Rio Grande, Rio Grande do Sul, Brazil. Email: isminasi@yahoo.com.br
^IINurse. Jaguarão, Rio Grande do Sul, Brazil. Email: lauranpassos@gmail.com
^IIINurse. Rio Grande, Rio Grande do Sul, Brazil. Email: ver_rosa@hotmail.com
^IVNursing student of the eighth semester of the Catholic University of Pelotas. Member of the  Study and Research Group in Nursing and Child and Adolescent Health. Rio Grande, Rio Grande do Sul, Brazil. Email: cassiana.duarte@hotmail.com
^VNurse. Doctorate in Nursing. Professor at the Nursing School and the Postgraduate Program at the Federal University of Rio Grande. Leader of the Studies and Research Group in Nursing and Child and Adolescent Health. Rio Grande, Rio Grande do Sul, Brazil. Email: giovanacalcagno@furg.br
^VINurse. Master degree of the Postgraduate Program in Nursing at the Federal University of Rio Grande. Member of the Study and Research Group in Nursing and Child and Adolescent Health. Rio Grande, Rio Grande do Sul, Brazil. Email: daiamoder@ibest.com.br

Keywords: Children; adolescent; violence; nursing.

INTRODUCTION

In Brazil, the violence is indicated as one of the leading causes of morbidity and mortality, no longer considered a problem of social and legal area to be included in the universe of public health^1,2. In different ways, it is a phenomenon that reaches the familiar reality composing serious life threatening, especially against children and adolescents.

The intra-family violence against children and adolescents represents a historical, complex, dynamic and challenging phenomenon, which involves individual, familiar, social, political and cultural factors. Usually occurs in a protected environment, at home, and therefore, it is difficult to detect³. It has been discussed in the scientific world from the 80´, encouraging the Statute of the Child and Adolescent (ECA)⁴ which made obligatory the notification of suspected or confirmed cases of violence by providing penalties for professionals and the responsible for health and education establishments that cease to communicate cases they know. It is understood that the victims´ protection starts with the notification, because from it, the whole system is operated for curbing violence and to escort the family⁵.

The notification can be defined as information issued by the health sector or any other organ or person, for the Guardian Council with the purpose of promoting care for the protection of children and adolescents, victims of mistreatments. It is a powerful instrument of public policy, because it helps to scale the violence in the family, to determine the need for investment in surveillance and care centers, and it still allows the development of research and dynamics knowledge of violence in family, enabling to cease the violence⁶. With the notification the professional recognizes special and urgent demands of the child and/or adolescent and calls the government to its responsibility. It unveils the fact and, usually, inhibits the aggressor to reoccur in the violence⁷.

The nurses are great allies to ensure the rights of children and adolescents, since they deal directly with the population, thus they can perform education actions for the prevention of violence, working the theme in partnership with the Guardian Council, conducting home visits, mapping families with potential risk for violence and, when the violence has already occurred, informing and notifying the cases the Guardian Council⁸. The nurse inserted into the basic unit of family health (BUFH) can provide better assistance to these children and adolescents through the notification.

However, it was evidenced that the diagnosis of cases as well as the notification is not easy. The lack of knowledge and skill combined with the fear make it not viable. Thus, it becomes important to nurses training for the management of cases. In this sense, the question that has guided this study was: Which actions performed by nurses of BUFH in violence situations against children and adolescents? Thus, the objective is the performance of BUFH nurses in the notification of violence cases against children and adolescents.

THEORICAL REFERENTIAL

The intra-family violence against children and adolescents is a phenomenon that is considered as a social problem, requiring from the health professionals to be positioned as mediator and articulator in the support network of victims protection, especially those who work in the basic care, confirmed every day as a gateway in the Unified Health System. A study about the theme showed that, despite being instituted a few years ago, the notification is still not part of the professional routine of the family health strategy (FHS) of Fortaleza, once 55.6% of participants have identified cases of child abuse and they did not notify them⁸.

The sub-notification, may be occurs because a kind of social acceptance of violence against children and adolescents exists, justified it by the need to educate, especially when they not produce visible and lasting physical damage. Other reasons for non-notification is the fear of the batterer, the belief that what happens in the family environment is private, interested in only those that are part of the environment and it should not be made public and the fact that the professionals do not receive answer of an adopted measure, believing that it will not help notifying it⁹.

The intra-family violence against children and adolescents is a complex and multifactorial problem whose consequences are extended from the individual to the social plan. The nurse is essential in its confrontation. It is up to the nurse to work primarily with the health promotion and violence prevention; to identify predisposing factors and warning signs; to suspect situations where domestic violence against children and adolescents can be happening; to know how to recognize even the milder forms of violence against children and adolescents and to conduct the notification¹⁰. A study showed that the nursing professionals that notify the problem are those who develop a dialogue with the victims of aggression, allowing them to know, from the users´ testimonials, the stories, the causes and situations where violence takes place¹⁰. It is evidenced that the approach to family violence is essential, given their impact on health and disease processes and in the development of children and adolescents victims. This decision is urgent, because the cycle of violence reproduces itself, tending to perpetuate, if there are not interventions capable of stopping it.

METHODOLOGY

It was held a study of descriptive and exploratory type, with qualitative approach, in the second half of 2010, in a town in southern Brazil. It has an estimated population of 345,181 inhabitants and it has 52 basic health units, of which 17 have the FHS, called by BUFHs.

In the study six nurses have participated working on BUFHs located in the urban area of the municipality. The inclusion criteria of the participants were: not to be on vacation or license in the period of data collection and to act directly with the population of the region assigned to BUFH. The data collection occurred through a semi-structured interview with each participant. They addressed issues relating to nurses´ performance of BUFH in the notification of violence cases against children and adolescents. They have been scheduled with each nurse, recorded and transcribed for analysis.

The process of analysis and interpretation of the data was developed by the thematic analysis¹¹. This technique is performed in three steps: the pre-analysis, the exploration of the material and the processing of results and interpretation. In the pre-analysis it is performed the literal transcription and the preparation of registration units. In the exploration phase of the material, the data were coded and grouped by similarities and differences, creating categories and, at the stage of processing of results and interpretation being selected the most significant speeches, which were discussed from scholars authors´ thematic.

All ethical precepts of Resolution No. 466/2012 of the National Health Council (NHC), which regulates the researches involving human subjects, were considered¹². The project was submitted to the Research Ethics Committee of the Catholic University of Pelotas and approved, receiving assent to its publication under Protocol No 30/2010. The lines of the nurses were identified by the letter N, followed by the number of the interview as a way to ensure their anonymity. All of them signed the Free Informed Consent Statement. This statement was signed in two copies, giving one copy to each participant.

RESULTS AND DISCUSSION

The data were organized into three categories: Notification of violence cases against children and adolescents; Difficulties faced to notify cases of violence; and Prevention of violence actions in the BUFHs.

Notification of violence cases against children and adolescents

The Statute of the Child and Adolescent (ECA) establishes the compulsory notification of cases of suspected or confirmed maltreatment, considering the non-communication of such events by health and education professionals an administrative infraction⁴. The notification is an alert that the child or adolescent and their family need help.

This study revealed that, generally, who detects violence cases is the community health agent, being, in some BUFHs, forwarded to the social assistant, that is who makes the notification. The U
Unit´s professionals try not to get involved directly in the situation.

We work with the community health agent at home. Normally, these are the professionals who communicate in a suspected case of violence. We don't work directly with these cases because it is complicated for us in the unit. (N1)

We forwarded the family to our social assistant and she is who takes the necessary providences. (N2)

Through the notification is expected to ensure that violence constitutes an event to be searched and taken in consideration in the care of children and adolescents. The victim and the family are leading to the Guardian Council, making the follow-up of the case. The health team, thus, shares responsibilities with the Guardian Council, through the notification^6,10.

The BUFH nurses, participants in the study, reported contacting the Guardian Council notifying the violence cases, through information by phone. However, they know the Compulsory Notification Form by the Health Ministry that should be filled with the guidance of tutelary advisors. However, it was found that, after notification, they do not usually follow the cases as a way to preserve.

We contacted the Guardian Council through the compulsory notification form and phone. They guide us how the fill it out. (N1)

The social assistant has a form and actually is everything with her. So, this form is filled out and forwarded to the Guardian Council (N2)

The nurses emphasized that, despite all the cases be notified, there is a lack of institutional support to support this act. They complained about the lack of secrecy by the Guardian Council, that exposes professionals with the community.

The Council ends up saying your name and the family unit. We were exposed and we don't want to get involved anymore. (N4)

It has already happened in some cases, the familiar to ask who made the complaint, and the counselor tell that it was the staff serving in the unit. (N3)

It was evidenced that the nurses are afraid to suffer reprisals by batterer or by relatives of the victims and that the lack of secrecy hinders the notification process. The lack of professional secrecy of public organs that receive the complaint of violence exposes BUFH professionals in front of the batterers. Such configuration represents an important obstacle, and may lead to sub-notification, because the low credibility of these institutions takes many professionals to suppress it in the revelation and support batterers on maintaining the pact of silence¹³.

Difficulties faced to notify cases of violence

In Brazil, despite the obligation and the recognition of the notification value, the professionals have difficulties in adopting it as default behavior¹⁴. To really effect the change of practice in the reception and resolution of violence cases, it is important to consider the need for training of health professionals in this area, thus acting on the existing gaps, building knowledge and practice in partnership with others, enhancing interdisciplinary and each case in its social context⁸.

There was a lack of knowledge of nurses as to what should be notified or the little value given to negligence and psychological violence, as reported cases only to notify physical and sexual violence.

Who practiced violence, who accused it, if it was physical or sexual violence. (N5)

There were cases that was not of violence, it was of abandonment. (N4)

The greater recognition of physical abuse as a violence´s type, it is possibly due to the signs visibility, such as bruises and injuries, presented on the victim, their dissemination by the media and by being suffered and feared by society in general¹⁵.

The nurses mentioned that they have difficulty evaluating the cases and to do the notification, because the family omits the information and keeps the situation of violence in secret. In addition, it was evidenced that, in some situations, they recognize the Guardian Council as inoperative, making them feel frustrated in having notified the case.

The father and the mother, in most cases, omit the case, so we can't work and investigate. They drink and we have no access to the child. (N2)

To report and the council being inoperative, not doing its role. It is frustrating. (N3)

The domestic violence occurs in an environment in which children and adolescents should, supposedly, feel protected. As the home is a private space, what happens inside is involved in an atmosphere of secrecy. This occurs, in part, because the relations of affinity and consanguinity between children/adolescents abused and batterers generate complacency of other family members, making difficult the revelation of the case to health professionals¹⁶.

The difficulties experienced by the Guardian Councils range from precarious physical structure to the lack of human resources and entail disbelief regarding the effective resolution of the reported cases. In this respect, it was evidenced that there are not studies that determine the effect of the measures taken by the services in the reduction and interruption of violence. The current overlapping roles of the care services for victims of violence, the communication system failures, the duplication of procedures and the distance between the attendance and the patient reveal and reinforce the fragmented vision and low resolution of services. Thus, the deployment of networks and strategies that improve the effectiveness of the services becomes essential¹⁷.

Prevention of violence actions in the BUFHs.

BUFHs nurses reported to perform prevention actions, promotion and awareness about violence against the child and the adolescent in levels of primary prevention through dialogue with the families in the consultations, home visits and group activities.

We talked a lot with the mothers, with the responsible for the children and we carry out prevention through direct dialogue with them. (N5)

The actions are in the consultations, in home visits through dialogue. We talked to one and other. (N2)

We do mothers groups, of children and adolescents. In these groups we work the issue of violence. (N6)
 
The nurses, work in the community together with the schools in the neighborhood, with the active group in Health and School Prevention Project (HSP), which is a school health program and which covers students and teachers of the schools.

We have a project that is along with the schools in the municipality. We work with health and school prevention (HSP). We discussed issues related to violence. (N3)

Now, entering the HSP, one of the themes that were raised by the teacher is violence. It is already on our list of subjects to be discussed. (N4)

There are, in some BUFHs, educational activities held during events that celebrate the holiday of the year, as children's day, Christmas, aiming to curb violent acts against children and adolescents.

We will have now an event in honor of children's day. It will be present the whole community, especially children and adolescents. We will have the educational part. We're going to call the Guardian Council that will address the Statute of the Children and Adolescent (ECA) with their parents and responsible who will be present. (N3)

I think that with the educational events, mainly in festive dates in a year, children's day, Easter and Christmas. We work well the issue of violence, the rights of children and adolescents. (N4)

The secondary level prevention actions are performed whenever violence cases come to them through the community health agent or of complaints by their own family or community, where appropriate notified to the Guardian Council.

We work with the community health agent. At home, they usually are those professionals who detect cases and communicate it. Thus, we notified it to the Guardian Council. (N1)

Generally, the family comes to tell us or we know through our community. In that sense, we are going to investigate. (N6)

It was evidenced that the nurses participating in the study did not follow the case of children and adolescents who are victims of violence at the tertiary level. They do only the capture of the case and forwarding the same to the responsible organ, which is the Guardian Council.

We do not work directly with these cases. It's complicated for us here in the unit. We only notice it and take it to the Guardian Council. (N1)

If the suspected case is confirmed we contact the Guardian Council over the phone and, from that, it is the Counsil who handles the case. We don't get involved anymore, do not go along with the outcome. (N5)

The study evidenced the nurses concern in act on prevention of domestic violence cases against children and adolescents. However, its performance is limited to notification when there is suspicion or confirmation of the violence. After forwarding the case to the Guardian Council they don't accompany its outcome.

Despite performing various activities of prevention and the issue of domestic violence to be part of the performance of health professionals, there is not a specific project of preventing and combating domestic violence, nor a policy focused on training these workers to deal with this issue, as several studies point out^7-10,13-17.

CONCLUSION

The study highlighted the performance of BUFHs nursesvin the notification of violence cases against children and adolescents. From the results, it was evidenced that, generally, who detects the cases are the community health agents. The suspected cases or confirmed are reported by the nurse to the Guardian Council via phone and by filling out the Notification Form. They don't follow the outcome of cases not to expose themselves, because they are afraid of suffering reprisals by the batterer or the family.

They face difficulties to notify violence cases, because they don't know what to notify, informing, generally, the cases of physical or sexual violence; do not receive information from the family, who keeps a secret about the fact and, in many cases, they report the ineffectiveness of the Guardian Council about the notified case, frustrating the efficaciousness of the notification. They perform actions of prevention of violence against children and adolescents in primary and secondary level, through thematic dialogue with families during the consultations, home visits and group activities. They maintain partnerships with schools and teachers working with children and adolescents.

It is concluded that it is important the role of the nurse in the notification of violence cases against children and adolescents identified in BUFHs, with a view to its inclusion in the community and access to dynamics of families there attended. This question is increasingly linked to the health area, pointing out the need for involvement and preparation of these professionals to face this challenge. It is necessary that they recognize that they must enter in the process of preventing violence, to identify risk conditions and attention to victims.

It is a need to extend the look about the violence phenomenon, not restricting it only to the biological aspects, but recognizing it as a problem with social, relational, economic, cultural and historical commitment. To notify the cases can help in the social denaturalization and deconstruction behaviors still accepted within families from the countryside, compromising the health and quality of life of children and adolescents.

REFERENCES

1. Martins CBG, Jorge MHPM. Maus-tratos infantis: um resgate da história e das políticas de proteção. Acta Paul Enferm. 2010;23: 417-22.

2. Gomes NP, Diniz NMF, Silva Filho CC, Santos JNB. Enfrentamento da violência doméstica contra a mulher a partir da interdisciplinaridade e intersetorialidade. Rev enferm UERJ. 2009; 17: 14-7.

3. Santos ACB, Braga RL, Lopes TMR, Paes LS, Vieira MAM. A enfermagem na violência intrafamiliar contra crianças e adolescentes: modos de cuidar. Rev Digital 2011; 16(156).

4. Senado Federal (Br). Estatuto da Criança e do Adolescente: Lei Federal 8.069/1990. Brasília (DF): Gráfica do Senado Federal; 1990.

5. Ministério da Saúde (Br). Portaria MS/GM nº 1.968, de 25 de outubro de 2001. Dispõe sobre a notificação, às autoridades competentes, de casos de suspeita ou de confirmação de maus-tratos contra crianças e adolescentes atendidos nas entidades do Sistema Único de Saúde. Brasília (DF): Ministério da Saúde; 2001.

6. Ministério da Saúde (Br). Impacto da violência na saúde às crianças e adolescentes.  Prevenção de violência e promoção da cultura de paz. Você é a peça principal para enfrentar este problema. Brasília (DF): Editora MS; 2009.

7. Oliveira MT, Samico I, Ishigami ABM, Nascimento RMM. Violência intrafamiliar: uma experiência dos profissionais de saúde nas Unidades de Saúde da Família de São Joaquim do Monte, Pernambuco . Rev bras epidemiol. 2012;15:166-78.

8. Luna GLM, Ferreira RC, Vieira LJES. Notificação de maus-tratos em crianças e adolescentes por profissionais da Equipe Saúde da Família. Ciênc saúde coletiva. 2010; 15: 481-91.

9. Ramos MLCO, Silva AL. Estudo sobre a violência domestica contra a criança em unidades básicas de saúde do município de São Paulo – Brasil. Saude soc. 2011; 20: 136-46.

10. Lima MCCS, Costa MCO, Bigras M, Santana MAO, Alves TDB, Nascimento OC et al. Atuação profissional da atenção básica de saúde face à identificação e notificação da violência infanto-juvenil. Rev baiana saúde pública. 2011;35(supl1);118-37.

11. Minayo MCS. Pesquisa social: teoria, método e criatividade. 29ª ed. Petrópolis(RJ): Vozes; 2010.

12. Ministério da Saúde (Br). Portaria nº 466/2012. Dispõe sobre diretrizes e normas regulamentadoras de pesquisa com seres humanos. Brasília (DF): Conselho Nacional de Saúde; 2012.

13. Andrade EM, Nakamura E, Paula CS, Nascimento R, Bordin IA, Martin D. A Visão dos Profissionais de Saúde em Relação à Violência Doméstica Contra Crianças e Adolescentes: um estudo qualitativo. Saude soc. 2011;20: 147-55.

14. Luna GLM, Parente EO, Moreira DP, Vieira LJES. Notificação de maus-tratos contra crianças e adolescentes: o discurso oficial e a práxi. Rev enferm UERJ. 2010; 18: 148-52.

15. Sorbo MF, Grimstad H, Bjorngaard JH, Schei B, Lukasse M. Prevalence of sexual, physical and emotional abuse in the Norwegian Mother and Child Cohort Study. BMC Public Health. 2013; 13: 186.

16. Siqueira AC, Alves CF, Leão FE. Enfrentando a violência: a percepção de profissionais da educação sobre a violação dos direitos de crianças e adolescentes. Educação 2012; 37: 365-80.

17. Martins CBG, Jorge MHPM. A violência contra crianças e adolescentes: características epidemiológicas dos casos notificados aos Conselhos Tutelares e programas de atendimento em município do Sul do Brasil, 2002 e 2006. Epidemiol serv saúde. 2009; 18: 315-34.