Technology to support nursing care for women in situations of sexual violence

Abstract

Objective

To develop an application to support the nursing process in assisting women in situations of sexual violence.

Methods

This is an applied research of technological production divided into three stages: elaboration of theoretical material through literature review; assessment of nursing diagnoses and interventions; mobile app development.

Results

The application “CuidarTech^® EnfPorElas” presents three navigation options: Nursing diagnoses and interventions, with 33 diagnoses and 613 nursing interventions, correlated and relevant to assist women in situations of sexual violence; Nursing Process, showing theoretical contents about the Nursing Process; Credits, the executing team.

Conclusion

The application is an unprecedented technology applicable to this clientele that can contribute to nurses’ work, directing assistance to women in situations of sexual violence through the nursing process.

Biomedical technology; Mobile applications; Nursing process; Nursing care; Sex offenses

Resumo

Objetivo

Desenvolver um aplicativo para apoio ao processo de enfermagem na assistência à mulher em situação de violência sexual.

Métodos

Pesquisa aplicada de produção tecnológica dividida em três etapas: elaboração do material teórico por meio de revisão de literatura; avaliação dos diagnósticos e intervenções de enfermagem; e desenvolvimento do aplicativo móvel.

Resultados

O aplicativo “CuidarTech^® EnfPorElas” apresenta três opções de navegação: Diagnósticos e intervenções de enfermagem”– com 33 diagnósticos e 613 intervenções de enfermagem, correlacionados e relevantes para assistência à mulher em situação de violência sexual; “Processo de Enfermagem” – exibe conteúdos teóricos sobre o Processo de Enfermagem; e “Créditos” - a equipe executora.

Conclusão

O aplicativo é uma tecnologia inédita aplicável a essa clientela que pode contribuir ao trabalho do enfermeiro, direcionando a assistência a mulheres em situação de violência sexual por meio do processo de enfermagem.

Tecnologia em saúde; Aplicativos móveis; Processo de enfermagem; Cuidados de enfermagem; Violência sexual

Resumen

Objetivo

Desarrollar una aplicación que sirva como apoyo en el proceso de atención de enfermería a mujeres en situación de violencia sexual.

Métodos

Investigación aplicada de producción tecnológica dividida en tres etapas: elaboración del material teórico mediante revisión bibliográfica, evaluación de los diagnósticos e intervenciones de enfermería y desarrollo de la aplicación móvil.

Resultados

La aplicación “CuidarTech^® EnfPorElas” presenta tres opciones de navegación: “Diagnósticos e intervenciones de enfermería” con 33 diagnósticos y 613 intervenciones de enfermería, correlacionados y relevantes para la atención a mujeres en situación de violencia sexual; “Proceso de enfermería” que exhibe contenidos teóricos sobre el proceso de enfermería, y “Créditos” al equipo ejecutor.

Conclusión

La aplicación es una tecnología inédita aplicable a este tipo de clientes que puede contribuir al trabajo del enfermero y orientar la atención a mujeres en situación de violencia sexual mediante el proceso de enfermería.

Tecnología biomédica; Aplicaciones móviles; Atención de enfermeira; Delitos sexuales; Proceso de enfermería

Introduction

Gender-based violence is a serious public health problem considered to be multi-causal and multifactorial, affecting not only women, but also children and family members, contributing to the dynamization of violence.(¹) It is important to highlight that sexual violence is one of the most cruel forms of gender violence, which occurs through the degradation of the body and the values of women. This type of abuse is usually accompanied by other types of aggression, such as physical and psychological violence.(¹,²)

The influence of intimate partner violence against women and sexual violence has led many countries to recognize the consequences and extent of the problem. With this, laws were enacted to criminalize sexual violence and that practiced by an intimate partner, provided legal, health and social services to women who were abused but little effort was made to prevent violence against women.(³)

Sexual violence is considered to be any conduct that requires women to witness, maintain or participate in unwanted sexual intercourse, whether through intimidation, threat, coercion or the use of force, that induces them to commercialize or use their sexuality in any way, preventing or limiting the exercise of their sexual and reproductive rights through coercion, blackmail, bribery or manipulation, as described in the Maria da Penha Law (Law 11.340/2006).(⁴)

In Brazil, in 2017, around 61 thousand rapes were registered, with an increase of 10.1% in relation to 2016. These data are only the tip of the iceberg, since there is a weakness in accounting for the incidences and prevalence of violence sexual abuse due to underreporting of cases, as many do not reach health and public safety services.(⁵,⁶)

Within the scope of the impact of this condition, it is observed that women who suffer sexual violence carry numerous consequences, such as damage to their physical, sexual, reproductive, emotional, mental, and social well-being. Moreover, this type of violence can lead to unwanted pregnancies, abortions and sexually transmitted infections (STIs), damages that can be accompanied by feelings of guilt, shame and fear.(²,³,⁷)

In this scenario, women in situations of sexual violence require care that requires time, listening and respect. In the health service, nurses are usually the first to have contact with the victims and, thus, they play a fundamental role in care. In this way, nurses must be trained to promote humanized care and adequate management together with the multidisciplinary team.(⁸)

The Nursing Process (NP) must be used to provide quality, safe and humanized care, capable of serving women in all their physical and emotional aspects. NP is an instrument that guides nurses’ clinical decisions, organizing care with effective and individual actions.(⁹,¹⁰)

The use of software, as a type of technology, that contemplates the NP stages, can facilitate nurses’ work and guide nursing team’s work in support of clinical decision considering a set of processes realized from daily experiences and research that develop organized and articulated knowledge with a specific practical purpose of generating knowledge and transforming empirical and scientific use.(¹¹,¹²)

In this context, aiming to provide systematic and qualified care, as well as to facilitate health documentation, communication between professionals and decision-making in care, the following guiding question was elaborated: what are the main diagnoses and nursing interventions that can compose a technology that supports NP for women victims of sexual violence? Thus, this study aimed to develop an application to support NP in assisting women in situations of sexual violence during hospital or outpatient care.

Methods

It is an applied research, of technological production, designed to survey the signs and symptoms present in women victims of sexual violence and nursing diagnoses, assessment of Nursing Diagnoses (ND) and Nursing Interventions (NI), and mobile app development.

First stage

The signs and symptoms present in women victims of sexual violence and ND were raised through a literature review using manuals from the Ministry of Health and the Brazilian Society of Gynecology and Obstetrics, as well as clinical guidelines from national and international gynecology and obstetric nursing, articles, theses and dissertations dealing with sexual violence against women. Then, the main signs and symptoms found in women victims of sexual violence that evidenced the basic human needs affected were mapped according to the Wanda de Aguiar Horta theoretical framework.(¹³)From the signs and symptoms, NDs were identified in the NANDA-I taxonomy, which, together with Wanda Horta’s Basic Human Needs, were adopted, as they were applied at the study institution.

Second stage

The second stage consisted of ND and NI assessment for women in situations of sexual violence. The evaluation of NDs was carried out through a Delphi panel, between September and November 2019, with a group of specialists made up of nurses who work in assisting women in situations of violence with at least 1 year of experience, linked to educational institutions. teaching, research, assistance or professional bodies of nursing in Espírito Santo State. The nurses were selected through snowball sampling for convenience, in which the previously selected judges indicate other experts. The exclusion criterion was that nurses were on vacation, leave or medical certificate. The invitation letters were sent to 17 judges, of whom 13 accepted to participate in the survey in the first round and only five participated in the second round of the Delphi panel. Each expert received an invitation letter and the Informed Consent Form (ICF) by e-mail. The form was made on an online electronic platform - (Google forms) which allows its viewing by the judges only after acceptance by the ICF with a 15-day return period between the stages. To assess the representativeness of each ND, the judges were allowed to mark with an “x” only one of the options on a Likert scale containing “1 - I agree” and “2 - I don’t agree”; after the answer, there was space available for comments and suggestions. After returning the forms, the data were tabulated using a Microsoft® Excel® 2010 program and the comments and suggestions were organized in an analysis chart. The agreement index between judges was taken into account when higher than 80.0%. NDs with agreement below 80.0% were later sent to the second round, as the Delphi method suggests, with due justifications based on a literature review, in response to observations made by judges for a new assessment. NDs that reached 80.0% of agreement had the NIs elaborated and based on literature reviews and on the book NANDA-NOC-NIC Connections that bring levels of evidence in their correlations.(¹⁴)Considering that these calls had already been made by a team of experts or in research, they were considered as already assessed.

Third stage

The third stage consisted of developing the mobile application. For this, the theoretical material previously elaborated, composed of ND and NI, was used to compose the screens and to design the conceptual map of the application. Then, the implementation and prototyping alternatives were generated to define the application’s functionalities. The application performance tests by the development team took into account usability and heuristics, composed of: 1) system visibility; 2) correspondence between the system and the real world; 3) user control and freedom; 4) consistency and standardization; 5) recognition instead of memorization; 6) flexibility and efficiency of use; 7) aesthetic and minimalist design; 8) prevention of system errors; 9) helping users to recognize, diagnose and recover from system errors; 10) help and documentation; 11) improvement of the human/device interaction, which must be pleasant and respectful to users; 12) physical interaction and ergonomics allowing universal access; 13) readability and layout.(¹⁵)The functionalities, interaction flows and operating logic of the application were built in partnership between the Laboratory and Observatory of Project Ontologies (Loop/UFES), the CuidarTech® Laboratory and the Laboratory of Studies on Violence and Health (LAVISA®/UFES). After corrections, the application will be registered. The study was approved by the Research Ethics Committee under CAAE (Certificado de Apresentação para Apreciação Ética - Certificate of Presentation for Ethical Consideration) 57930016.0.0000.5060.

Results

Characterization of the sample of judges

Of the 13 judges selected, 70% had more than five years’ experience in assisting women victims of violence. Additionally, 15% had a doctorate, 23% had a master’s degree and the others had a specialization in nursing. As for the work performed, 13% of nurses were state technical references for assisting women in situations of violence, 13% nurse professors at a federal university, 40% in the state’s basic health unit and 34% work in a hospital.

Assessment of Nursing Diagnoses and Interventions

Initially, a survey of the signs and symptoms most commonly found in women in situations of sexual violence was carried out; subsequently, a cross-mapping with the NANDA-I taxonomy ND was carried out, in which 33 diagnoses were evidenced. Then, these diagnoses were grouped into psychosocial/psychospiritual needs (72.7%) and psychobiological needs (27.3%), as proposed by Wanda Horta. In the first round of the Delphi panel, the judges evaluated 32 diagnoses with an agreement index above 80.0% and the diagnosis “Ineffective health control”, which obtained an index of 76.9%, was validated in the second round. Thus, 100% of diagnoses were considered adequate and representative of nursing care for women in situations of sexual violence. After the diagnosis assessment stage, 613 NI were developed.

Application “CuidarTech^® EnfPorElas”

In this way, “CuidarTech® EnfPorElas” was designed to support nurses or students during outpatient or hospital care for women in situations of sexual violence and assist in NP/consultation registration. The application is being finalized and, after the end of the testing and registration, it will be available for free to be loaded in the application stores. In order to allow quick access for users, a list of diagnoses was prepared with the NI that represent the care practice for this clientele. Figure 1 illustrates the application screen with the main menu and the three navigation options: “Nursing Diagnosis and Interventions”, “Nursing Process”, “Credits; Terms of use.

Figure 1
Main menu of “CuidarTech® EnfPorElas”

The option “Diagnosis and Interventions” contains a list with 33 ND distributed by basic human needs, with 9 DN related to psychobiological needs and 24 DN related to psychosocial/spiritual needs, correlated with 613 NI. When selecting a ND, users visualize the diagnoses’ concept, and can click on “See Interventions”. When clicking on this button, a list will appear with the main NI for the execution of the care pertinent to the selected diagnosis, as observed in Figure 2, with the diagnosis “Anxiety”, following for the interventions.

Figure 2
Navigability between Diagnosis and Nursing Interventions

The “Nursing Process” option presents theoretical contents with a description of the concepts and references about NP and the types of classification: NP, Theory of Basic Human Needs, NANDA-I, NIC, NOC and ICNP® (International Classification for Practice of nursing). Such content was prepared based on the latest publications on these topics.(¹⁴,¹⁶-¹⁸)In the item “Credits”, there is information from the team responsible for preparing the application and content.

Discussion

The use of application-type software in nursing care has been progressively increasing, since this tool is capable of assisting nurses in care management, favoring knowledge and familiarity with nursing classifications, in addition to optimizing the time of patient-centered care. and maximize service quality by facilitating registration and communication between team members.(¹⁹)

In this context, “CuidarTech® EnfPorElas” is a technological assistance innovation with the purpose of assisting clinical reasoning and the registration of care for women in situations of sexual violence, both in hospital and outpatient care, contributing to a humanized and quality care, based on scientific evidence, through the NP application.

The proposed application uses ND and NI based on a standardized nursing language system, according to ISO 18.104: 2014, which is adequate to support electronic documentation and assist in the formation of diagnostic expressions and nursing actions. This study points out that different standardized terminologies such as NANDA-I, ICNP^Ò, NIC, follow the categorical structure of ISO 18.104: 2014. The structure proposed in the application, ND, contains only the title with focus, judgment or clinical finding. Thus, these diagnoses can be found in both NANDA-I and ICNPÒ. Regarding NI, they follow the structure of ISO18.104: 2014.(²⁰)

It is important to consider that the selected judges were inserted in different work contexts, such as teaching, health management, primary and tertiary care. Some of the workplaces, especially those in the hospital environment, have a NP systematic application with the NANDA-I classification. However, one health management professional and two primary care professionals requested changes in the ND titles statements, despite knowing about the NANDA-I diagnoses and their importance for nursing practice, they were unaware of how their elaboration and validation occurs. This was evidenced by questions about changes in the nomenclature of the statement of diagnoses, which demonstrates the lack of knowledge and familiarity in relation to the diagnoses proposed by the NANDA-I taxonomy.(²¹)

However, it is known that NANDA-I diagnoses are standardized and cannot be modified independently by nurses, being necessary that the nurse knows the defining characteristics and related factors to differentiate one diagnosis from the other and, therefore, the proposed modifications were not obeyed.(¹⁶,¹⁷)

It is worth mentioning that there are still nurses who do not feel prepared to assist women in situations of violence. This factor implies professionals’ insecurity in attending to this group as well as reveals flaws in the issue of permanent education.(⁸,²²)

Despite understanding the repercussions of sexual violence, nurses assume a stance of not knowing what to do when care goes beyond physical violence, which is easier to identify and act according to the traditional teaching model in undergraduate courses.(²³)

Proposing a clinical assessment with a broad and comprehensive look, “CuidarTech® EnfPorElas” brings together a greater number of DN related to psychosocial/spiritual needs.

It is also observed the difficulty of professionals with the theme, due to lack of reflection and knowledge about what violence is and its facets. This is the result of the lack of discussion and approach of relevant theoretical references that provide support for decision-making before the problem during the graduation process. As a result, the need for continuous training of professionals becomes imperative, promoting environments for discussion and reflection on violence as a public health problem, in order to sharpen sensitivity for the identification of cases and for the art of caring in a comprehensive and humanized way.(²⁴)

In this regard, the use of an application can helps nurses and nursing students in the development of clinical judgment and the diagnostic reasoning process. Furthermore, this technology can contribute to care services for victims of sexual violence, by facilitating nurses’ understanding of care and directing NP execution and documentation in their daily practice.(²⁵)

It is worth pointing out that the choice of NI for each diagnosis should be based, primarily, on nurses’ clinical judgment.(¹⁴)

Finally, humanized nursing care for women in situations of sexual violence contributes to the fact that they continue to live with dignity in the search for the physical and psychological restoration affected by the violence. For this, it is important for professionals to view sexual violence as a public health problem, highlighting nursing care with well-defined planning actions and mechanisms that meet victims’ individual needs.(²⁶)

As study limitations, the need to conduct usability tests with healthcare professionals is emphasized. The tests were carried out in simulated environments through an Android® emulator, which is a program that simulates the experience of running the operating system of applications made for it, within another computer operating system, such as Windows®.

Conclusion

This study described the development of “CuidarTech® EnfPorElas”, which is an interactive, objective and clear tool, composed of ND and NI, which facilitates the nurses’ understanding of the assistance to victims of sexual violence, mitigating professionals’ feeling of helplessness and supporting their clinical reasoning for the execution of a ND based on a nursing classification and theory, with care based on scientific evidence. The application was considered reliable and adequate, according to experts’ assessment on the subject and, in the future, it is intended to develop application studies to assess the impacts of the use of technology in nursing care. The application uses ND and NI according to ISO 18.104: 2014, which is suitable for different standardized terminologies, such as NANDA-I, NIC and ICNP^Ò. Considering the importance of technical knowledge for constructing the application, the design team’s and computer science’s contribution in interdisciplinary production stands out. These partnerships have the potential to expand the knowledge of teams involved in relation to the specificities of each area. However, it also presents the limit for the health team to need to understand basic concepts of other related areas in order to develop new health technologies.

Acknowledgments

We would like to thank the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) and to the Federal Council of Nursing (COFEN – Conselho Federal de Enfermagem) through the Public Notice CAPES/COFEN 27/2016 - Financing Code 001.

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Publication Dates

• Publication in this collection
  26 Nov 2021
• Date of issue
  2021

History

• Received
  9 May 2020
• Accepted
  1 Mar 2020