Self-reported violence by nursing students in the context of undergraduate studies

Violencia auto-referida por estudiantes de enfermería en el contexto de grado

ABSTRACT

Objectives:

to identify the characteristics of violence in the context of the teaching and learning of the undergraduate Nursing course, from the perspective of students.

Methods:

quantitative, cross-sectional study, developed with 208 undergraduate students in Nursing. The data was obtained through the application of a survey questionnaire and processed by descriptive and bivariate statistics.

Results:

of the participants, 69.2% (n = 144) have experienced some kind of violence. Violent acts of a psychological nature were the most frequent, but there were also reports of physical, sexual violence and deprivation or abandonment. Violence was practiced in a theoretical and practical learning environment. Teachers and classmates were the most frequent perpetrators. Most students had no reaction, told friends, family, and colleagues, or pretended that nothing happened in the face of the violent acts.

Conclusions:

violence is present at various moments in the undergraduate Nursing course and can negatively impact the quality of training in the area.

Descriptors:
Violence; Learning; Nursing; Education, Nursing; Students

RESUMEN

Objetivos:

identificar características de violencia en el contexto de enseñanza aprendizaje de grado en Enfermería, bajo la perspectiva de estudiantes.

Métodos:

estudio cuantitativo, transversal, desarrollado con 208 estudiantes de grado en Enfermería. Datos obtenidos mediante aplicación de cuestionario tipo survey y tratados por estadística descriptiva y bivariada.

Resultados:

de los participantes, 69,2% (n = 144) ya vivieron alguno tipo de violencia. Actos violentos de naturaleza psicológica fueron los más frecuentes, pero también hubo relatos de violencia física, sexual y de privación o abandono. Violencia ocurrió en ambiente de aprendizaje teórico y práctico. Profesores y colegas de clase fueron los perpetradores más frecuentes. Mayoría de los estudiantes no tuvo reacción, contó para amigos, familiares y colegas o aparentó que nada pasó delante de los actos violentos.

Conclusiones:

la violencia está presente en diversos momentos en el grado en Enfermería y puede impactar negativamente la calidad de la formación en el área.

Descriptores:
Violencia; Aprendizaje; Enfermería; Educación en Enfermería; Estudiantes

RESUMO

Objetivos:

identificar as características da violência no contexto do ensino-aprendizagem da graduação em Enfermagem, sob a perspectiva de estudantes.

Métodos:

estudo quantitativo, transversal, desenvolvido com 208 estudantes de graduação em Enfermagem. Os dados foram obtidos mediante aplicação de questionário tipo survey e tratados por estatística descritiva e bivariada.

Resultados:

dos participantes, 69,2% (n = 144) já vivenciaram algum tipo de violência. Os atos violentos de natureza psicológica foram os mais frequentes, mas também houve relatos de violência física, sexual e de privação ou abandono. A violência foi praticada em ambiente de aprendizagem teórico e prático. Professores e colegas de classe foram os perpetradores mais frequentes. A maioria dos estudantes não teve reação, contou para amigos, familiares e colegas ou fingiu que nada aconteceu diante dos atos violentos.

Conclusões:

a violência está presente em diversos momentos na graduação em Enfermagem e pode impactar negativamente a qualidade da formação na área.

Descritores:
Violência; Aprendizagem; Enfermagem; Educação em Enfermagem; Estudantes

INTRODUCTION

Violence is a complex social phenomenon, rooted in social relations and present in human daily life since prehistoric times. Multiform in origin and manifestations, is defined by the use of physical force or power against you, another person or group of people, so that injury, death, psychological harm, limitation in development, or deprivation is likely to occur⁽¹⁾.

Due to its global relevance and frequent approach in various fields of knowledge, violence can be conceptually classified in several ways. According to the World Health Organization (WHO), violent acts may be interpreted, based on their etiology, as self-directed violence, interpersonal violence and collective violence; and, depending on the nature of the act, it may be physical, sexual, psychological and of deprivation or abandonment⁽¹⁾.

Regardless of how it manifests itself, violence penetrates the entire social fabric, and there is no direct or uni-causal relationship with specific population groups. Thus, although there is a greater prevalence of violent acts in social strata of greater social vulnerability⁽²⁾, the phenomenon is not only linked to a portion of the population and has no precise borders or geographical delimitations⁽³⁾. Violence is present in all places where there is social interaction, spreading in rural and urban environments, at work, in schools, in families, in religious institutions, in politics and in other diverse sectors⁽⁴⁾.

As an integral field of social reality, education and, consequently, teaching and learning processes, are not free from violent acts. Violence crosses the learning environment from basic education to higher education, presenting itself in manifestations that range from psychological pressure, moral harassment and negligence, to sexual harassment and physical aggression^(5-8).

As far as higher education is concerned, health courses have high numbers of students who experienced violence during graduation, which may occur because graduations in this area require the development of complex skills and competencies, which occurs in relationship movements with the other, especially with patients and relatives^(8-10). Specifically, regarding nursing, there are still gender issues, devaluation, low social status and challenging working conditions of the profession, aspects that encourage too much competitiveness among students^(11-12).

International investigations indicate that violence is present in theoretical and practical contexts in the undergraduate Nursing, reaching most students^(13-15). The same occurs in the Brazilian scenario, where several types of violence permeate learning processes^(16-18). In both contexts, research shows that violence produces weaknesses in education, limiting learning and generating several consequences, such as anxiety, depression, decreased learning and willingness to give up the discipline or the Nursing course.

In this sense, one wonders: What are the types and characteristics of violence experienced by students during the teaching and learning context of the Nursing undergraduate program??

OBJECTIVES

To identify the characteristics of violence in the context of the teaching and learning of the undergraduate Nursing course, from the perspective of students.

METHODS

Ethical aspects

This research fulfills all the orientations of the Resolution 466/2012 of the National Health Council. It was developed with the agreement of the HEI involved, as well as the positive opinion of the Committee of Ethics in Research, on October 04, 2018. At the time of the invitation to participate in the research, all students were informed of the risks/benefits of the study, the free choice to integrate the research and signed a Free and Informed Consent Term.

Study design

A quantitative study, with a cross-sectional design. For its construction, the STROBE script was used as the basis.

Study location and time

The study was developed in a Higher Education Institution (HEI) in the South of Brazil, which has more than a hundred undergraduate courses. HEI has been offering undergraduate Nursing courses for more than 50 years, has several research programs, extension and a consolidated graduate program.

The Nursing degree is organized in ten semesters, with theoretical and practical classes. The specific faculty of the department is composed of more than 60 professionals, most of them with doctoral degrees in Nursing or in areas integrating the Health Sciences. To obtain the Bachelor of Nursing degree, students must complete 4,980 class hours of activity.

The beginning of the course is marked by theoretical classes, with subjects that aim to build with the students a theoretical basis about the biological sciences and health. During the semesters, the student is gradually inserted in the contents and specific practices of nursing, until reaching the stage of curricular internships, which are developed almost entirely in health services. The average in theoretical classes is 40 students; in theoretical-practical classes, in the services scenario, the average is six students per teacher instructor; and in supervised internships the quantitative depends on the practical context chosen by the student. The curricular internship includes the last two semesters of the course, when the student acts under the direct supervision of the service preceptor nurse, with guidance from the teachers according to the needs expressed by those two.

The data collection took place between March and April 2019, by means of a survey type questionnaire.

Study population

The research included students over 18 years of age, regularly enrolled between the 2nd and 10th semesters of the course and who had been active in the HEI survey for at least one year. Students with a health treatment license, with absences of other kinds and those who were enrolled in the 1st semester of graduation were excluded. This last exclusion criterion was established because it was a moment crossed by many changes in the lives of students, which could generate reports of violence not directly related to the context of the teaching-learning of graduation, causing bias in the collection of data.

Students were invited to participate in the research in person, at the beginning or end of the theoretical classes. The researcher contacted the professors requesting a moment to present the project to the students and invite them to participate. The number of students enrolled between the 2nd and 10th semesters of the Nursing course in the first semester of 2019 was 323. Of this total, 208 participated in the survey, equivalent to 64.4% of the total.

Study Protocol

Because there is no validated instrument in the scientific literature with content capable of providing the necessary information to identify self-reported violence in the context of undergraduate teaching-learning, the questionnaire was produced exclusively for research purposes. In this way, the researchers conducted bibliographic research in the format of integrative literature review ⁽¹⁹⁾ and, using as theoretical basis the categorization of the nature of violence (WHO)⁽¹⁾, elaborated the instrument.

This was built in meetings with the research team, composed by two professors PhD in Nursing, one PhD student and one MSc student. For such construction, information from the literature review and WHO documents were used as a way to evaluate in detail each topic to be included. After finishing this stage, the instrument was analyzed by two professors with PhDs in Nursing: one with expertise in nursing education and the other in moral stress in nursing students, who analyzed the instrument separately for relevance and applicability. The questions regarding socio-demographic data and the topic of violence related to deprivation and abandonment were readjusted. The other issues did not need to be changed, according to the evaluators.

The questions regarding socio-demographic data and the topic of violence related to deprivation and abandonment were readjusted. The other issues did not need to be changed, according to the evaluators. In the socio-demographic data, the variables of collection were: age, gender, sexual orientation, place of residence prior to graduation, time and place where he currently resides, self-declared ethnic group and semester of the course. For the identification of violence, the same variables were used for all the described natures, contemplating: having been (or not) the target of violence, number of times it suffered violence, period of the course, characteristics of the violent act, characteristics of the learning context (theoretical or practical), aggressor or aggressors and student’s reaction to the violent act. The instrument was built to obtain information about situations of self-reported violence.

The data collection was carried out by only one member of the research team, with the objective that the application of the instrument was performed in the same way for all participants. At the time of application, the researcher responsible explained the objectives of the study and the concept of each nature of violence present in the instrument. Before the students began to fill out the questionnaire, he made sure that the students had understood the proposal of all natures of violence addressed in the instrument. As for the latter, it was guided by the researcher and self-applied in an individual way by the participants, who took, on average, 20 minutes to answer it.

Analysis of results and statistics

A descriptive analysis of the data was carried out, presenting the results in absolute and relative frequency, both for the socio-demographic data and for those related to the identification of violence experienced in the context of the teaching and learning of graduation.

The chi-square test was used to analyze the associations of ethnicity and sexual orientation with the violence suffered. Response options for ethnic and sexual orientation variables were grouped due to the low frequency of observations in certain response categories. The participants were classified into “Whites” and “Non-whites” (black, brown, indigenous, others) in relation to the ethnic group; and into “Heterosexuals” and “Non-heterosexuals” (homosexuals, bisexuals, pansexual, others) in relation to sexual orientation. The violence suffered was identified based on the occurrence report, and participants were classified as “Assaulted” (regardless of the type of aggression) and “Not Assaulted. Statistical significance was adopted for α = 0.05. The description of the frequency of reports of violence experienced was calculated taking into account the recurrence of responses. Thus, the same student may have reported more than one type of violence, including with different frequencies, and all were considered. That is, if a student had hypothetically suffered physical violence only once and psychological violence between two and five times, both responses would integrate the totality of cases, since the percentage is calculated according to the number of times the response is repeated. The descriptive analyses and the conduct of the tests were performed in IBM SPSS Statistics 20.0 software.

RESULTS

Regarding the characterization of the participants, Table 1 presents information on age, self-declared ethnic group, gender, sexual orientation and semester of the course.

Table 1
Characterization of participants (N = 208), Florianópolis, Santa Catarina, Brazil, 2019

	n	%
Age
19 years or more	29	13.9
20 to 24 years	136	65.4
25 to 29 years	26	12.5
30 to 34 years	10	4.8
35 years or more		3.4
Ethnic group
White	154	74.0
Non-white	52	25.1
Did not answer	2	1.0
Gender
Cisgender Woman	185	88.9
Cisgender Man	18	8.7
Queer*	1	0.5
Did not answer	3	1.4
Other	1	0.5
Sexual orientation
Heterosexual	167	80.3
Not heterosexual	38	18.3
Did not answer	3	1.4
Course semester
2nd semester	24	11.5
3rd semester	18	8.7
4th semester	38	18.3
5th semester	26	12.5
6th semester	14	6.7
7th semester	26	12.5
8th semester	20	9.6
9th semester	21	10.1
10th semester	20	9.6
Did not answer	1	0.5

• Note:
• ^*
  English term used to designate people who do not identify with the model of heterosexuality or gender binaries.

It is noticeable that the students of the HEI Nursing course investigated are mostly young women, of white ethnic origin and heterosexuals. Attention is drawn to: the small number of students over the age of 35; the presence of only one self-declared participant out of the cisgender pattern; the fact that less than 20% of the participants do not belong to the heterosexual pattern; the presence of only 25.1% of non-white people (among them, only one indigenous student and 13 black students).

In addition to the data presented in Table 1, 34 students (16.3%) reported a change of state to study at the HEI investigated. Of these, 18 (8.7%) came from states in southern Brazil; 11 (5.3%) from the Southeast; 3 (1.4%) from the North; two (1.4%) from the Northeast; and one (0.5%) from the Midwest. There were no foreign students that met the criteria for inclusion in the research.

Of the 208 students researched, 144 (69.2%) declared having already experienced some type of violence in the context of undergraduate teaching-learning, demonstrating that violence presents itself as a constant phenomenon in this environment. In Table 2, it is possible to observe, according to the typological classification of the phenomenon, the number of times that students declared that they suffered violence, the environment in which it occurred and the author of the violence, as well as the proportions relative to the total of reported cases. The sum of cases presented in the table is related to the number of times the student indicated having suffered the violence; thus, the item “total” refers to how many times that same response was signalled by the students, considering that they may have experienced the violence in both theoretical and practical classes and internships, and that the authors may have been more than one person.

Table 2
Characteristics of Self-reported Violence by Undergraduate Nursing Students, Florianópolis, Santa Catarina, Brazil, 2019

	Physical	Sexual	Psychological	Deprivation/ Abandonment	Total	%
Frequency
Once	6	2	30	12	50	25.1
2 to 5 times	4	2	73	28	107	53.8
6 to 10 times	0	0	13	6	19	9.5
More than 10 times	0	0	15	8	23	11.6
Total of answers	10	4	131	54	199	100
Context where they suffered violence
Theoretical classes	1	0	54	27	82	30.7
Theoretical and practical classes	4	1	54	24	83	31.1
Internships	6	3	48	22	79	29.6
Other	1	0	19	3	23	8.6
Total of answers	12	4	175	76	267	100.0
The perpetrator of violence
Patient and/or family member	0	2	6	0	8	2.9
Professor	8	1	116	50	175	64.6
Classmate	2	0	39	14	55	20.3
Service Professional	1	1	22	6	30	11.1
Other	0	0	1	2	3	1.1
Total of answers	11	4	184	72	271	100.0

Regarding the learning context where the violence occurred, the frequency of psychological violence and deprivation or abandonment is very close in theoretical, theoretical-practical contexts and in stages. Regarding physical and sexual violence, there is a predominance of events in the practical context, represented by theoretical-practical classes and internships.

As for the authorship of violent acts, it calls attention to the high frequency of responses indicating “teacher” as the perpetrator of violence, with emphasis on psychological violence, in which the mention of this agent is almost three times greater when compared to “classmates. In addition, it is noted that, regarding sexual violence, the variable “patient and/or family member” was responsible for the highest frequency of acts.

The associations of ethnicity and sexual orientation with the violence suffered are presented in Table 3. The prevalence of violence suffered was slightly higher in non-white participants (73%), compared to whites (68%), and in self-declared non-heterosexual participants (71%), compared to heterosexuals (68%). However, the associations were not statistically significant; suggesting that the results observed in the sample may not represent the study population and therefore should be interpreted with caution.

Table 3
Prevalence of self-reported violence in Nursing graduation, according to ethnic group and sexual orientation, Florianópolis, Santa Catarina, Brazil, 2019

Variables		Total	Not assaulted	Assaulted	χ2	p
		n	n (%)	n (%)
Ethnicity					0.4388	0.508
	White	154	49 (31.8)	105 (68.2)
	Not white	52	14 (26.9)	38 (73.1)
Sexual orientation					0.1122	0.738
	Heterosexual	167	53 (31.7)	114 (68.3)
	Not heterosexual	38	11 (28.9)	27 (71.1)

• Note: χ², statistics of the chi-square test; p, significance of the test associated with ethnicity and sexual orientation to self-reported violence

Regarding the reaction and conduct of students to an act of violence, it is possible to observe, in Table 4, the quantity of reported and unreported violence, the main reasons why students did not tell other people about the violent acts, as well as the proportions of the total cases reported. These data may indicate possible fears of the students regarding the violence suffered and the support networks of these subjects.

Table 4
Reaction and conduct adopted by Nursing students in the face of violence experienced during graduation, Florianópolis, Santa Catarina, Brazil, 2019

	Physical	Sexual	Psychological	Deprivation/ Abandonment	Total	%
How did they react?
Did not have a reaction	7	0	56	24	87	23.5
Asked the person to stop	2	1	17	5	25	6.8
Told friends/family	3	1	56	16	76	20.5
Told a coleague	3	0	53	23	79	21.4
Reported to a teacher	3	0	16	3	22	5.9
Tried to pretend that nothing happened	0	2	36	9	47	12.7
He tried to defend himself physically	0	0	1	0	1	0.3
Sought advice	0	1	17	4	22	5.9
Opened lawsuit	0	0	1	0	1	0.3
Other	0	1	7	2	10	2.7
Total	18	6	260	86	370	100.0
Told someone about what happened?
Yes	9	4	117	40	170	85.4
No	1	0	14	14	29	14.6
Total	10	4	131	54	199	100.0
Why they didn't tell us about what happened?
It was not important	2	0	2	1	5	11.1
They considered that no action would be taken	0	0	10	10	20	44.4
They felt ashamed	0	0	7	5	12	26.7
They got scared	0	0	2	1	3	6.7
They felt guilty	0	0	2	1	3	6.7
Didn't know who to report to	0	0	2	0	2	4.4
Other	0	0	0	0	0	0.0
Total	2	0	25	18	45	100.0

It is noticeable that in the case of physical and sexual violence, students constantly have no reactions or pretend that nothing happened while experiencing such a violent act, these being the two variables with the highest frequency of responses. In the case of psychological violence and deprivation or abandonment, it is noted that students have found it easier to report what happened to friends, family, and colleagues; however, the frequency of non-communication of the events to other people has also been highlighted.

DISCUSSION

Violence of a psychological nature and of deprivation or abandonment were the most frequent, reaching a considerable portion of the participants. Studies allow us to infer that this is not an exclusive reality of the researched context, considering that incivility, verbal aggression, bullying and moral harassment, classic examples of violence of psychological nature, are present in nursing courses in other regions of Brazil^(16,18) and in countries like Australia, Turkey and Egypt^(15,20-21). Nevertheless, situations of neglect, insufficient pedagogical orientation/instruction and the demerit of students’ intellectual capacities, characteristics related to violence of deprivation or abandonment, also appear on a recurrent basis^(22-23).

Regarding violence of a physical and sexual nature, there is a decrease in the frequency of events and a trend of events in the practical field. Similar results were found in studies conducted in Australia^(15,24), in which there is also less occurrence of violence of these two natures, which generally occur in the hospital context and are perpetrated by patients, colleagues and professionals in the service.

Specifically on violence of a sexual nature, although bivariate analysis did not show statistical significance, it was observed that acts of violence were reported more frequently by non-white and non -heterosexual students. In this sense, international research, carried out with students of Nursing in Turkey⁽¹³⁾ and in South Africa⁽²⁵⁾, found that racial tension among students is common in the context of graduation, as well as their exposure to embarrassing and violent situations related to markers of ethnic group, gender and sexuality.

Regarding the learning environment where there are more frequent cases of violence, both theoretical and practical spaces are noted as fields of reproduction of these acts. However, by joining the data from theoretical-practical classes and internships, taking into account that they are carried out, essentially, in the practical context, one notices a greater constancy of the phenomenon in this field. Such information converges with the results of investigations carried out in Brazil and in other countries^{(14,17,24,26-27)} and, probably, is related to the context of clinical practice, as a result of setting up a learning scenario that students are not used to, of involving direct care of patients, often in critical health conditions, of constant contact with family/accompanies and of joint work with nursing workers and other professional categories⁽²⁰⁾.

On the other hand, situations of violence have also been identified in theoretical classes - in this case, they come closer to the characteristics of psychological violence and of deprivation or abandonment. The supporting factors for the occurrence of these situations are related to the insufficient competence of nursing instructors, the evaluation processes, the non-understanding and stressful learning environment, the traditionalism in pedagogical practices, the lack of respect and patience, the rigid hierarchical relations and excessive competitiveness^(16,22). These factors may explain the predominance of the figure of the teacher and classmates as authors of the violence indicated as more frequent.

As for teachers, situations of violence can be intimately related to the pedagogical postures adopted. Traditional teaching postures, based on vertical learning methods in which the teacher is the main agent of the process, may contribute insufficiently to the construction of knowledge, create excessively rigid hierarchies and establish power relations between teachers and students^(17,26). Research shows that students experience situations of violence with these characteristics in both theoretical and practical contexts and that teachers, instead of providing moments of knowledge construction based on dialogue and respect, judge, humiliate and bring out feelings of fear in students^(16-17,26).

In the case of violence among students, competitiveness and lack of understanding, these factors are related to increased incivility, stress and, consequently, the occurrence of violent situations in the context of undergraduate teaching-learning^(16,26). This violence emerges, in large part, due to the desire of students for prominence among their peers and the desire for student recognition through academic performance, usually measured by assigning grades to the activities developed⁽²⁸⁾. In this context, the perception of the other as a colleague/classmate may give way to competition and rivalry among students, producing violence.

As for the reaction to the acts of violence, it can be seen that a group of students did not react, pretended that nothing happened or did not tell about what happened, demonstrating the difficulty in sharing with other people the violence suffered and the disbelief of taking action on the acts that occurred. Results of other investigations indicate that this may be linked to factors such as the fear of suffering negative consequences from the instructors/teachers and the doubt of the correct direction of the case^(13,23).

These results may indicate the transformation of violence into a habitual event in the context of undergraduate teaching-learning, which is also evidenced by national and international studies^(17-20) and represents a weakness for nursing training, due to all the consequences generated by it. By experiencing violence, students develop feelings of nervousness, fear, sadness, demotivation and anxiety, resulting in increased student absenteeism, difficulties in communication with teachers, colleagues, patients and other health care professionals^(13,15-16). The occurrence of violence in the university context is also associated with the development of psychosomatic pathologies such as burnout syndrome^(29-30).

Study limitations

A limitation of the study lies in conducting the research in a single institution that offers the undergraduate course in Nursing in the state researched. It is believed that the expansion of the sample through the inclusion of other HEIs would be able to highlight possible similarities and differences of the phenomenon, contributing to a deeper understanding of the roots, manifestations and repercussions of violence. In addition, the absence of a pre-test of the survey questionnaire may also have limited, to some extent, the deepening of data collection.

Contributions to the Area

The study contributes to nursing education because it exposes a phenomenon that directly influences the context of undergraduate teaching and learning and the lives of students. The data show that violence is present in the undergraduate Nursing at various times, causing a series of weaknesses for the professional construction of future nurses.

In this sense, theory and practice cannot configure two realities; they need to be united so that, in any area of life, people can exist with dignity. This work invites and instigates people involved with nursing training to rethink the theory-practice relationship in the context of teaching-learning. By foreseeing that violent acts are present in the daily routine of graduation and, many times, are stimulated by the pedagogical act, teachers, course/discipline coordinators and other involved actors can reflect on measures to minimize the occurrence of violence and promote a more understanding, welcoming and ethically committed formative environment with a humanistic formation, as well as the nursing care offered to the population.

CONCLUSIONS

Violence is present at various times in the nursing degree and can negatively impact the quality of training in the area. The most frequent natures of violence were psychological and deprivation or abandonment, and the least frequent were physical and sexual violence.

Students experience violence in a theoretical, theoretical-practical and practical environment. Most situations have occurred more than once, especially in the case of psychological violence and deprivation or abandonment. The perpetrators are mostly teachers and classmates, but patients, family members of patients and health service workers also appear as authors of the acts.

The study demonstrates the need to investigate more appropriately issues that predispose students to suffer violence, such as those related to gender, ethnic group, and sexual orientation. Deepening in this direction may indicate the existence of population groups more vulnerable to violent acts and point out more effective measures to confront the phenomenon.

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Publication Dates

• Publication in this collection
  14 July 2021
• Date of issue
  2021

History

• Received
  18 Aug 2020
• Accepted
  21 Nov 2020