Social Representations of nurses on the approach to children and adolescents who are victims of violence

Objective: to analyze social representations from the perspective of the structural aspect about the nurses’ approach to children and adolescents who are victims of violence, comparing primary, secondary and tertiary health care services. Method: an analytical research study with a qualitative approach under the methodological theoretical framework of the Theory of Social Representations from the Central Core Theory. A total of 76 nurses participated in the study: 30 from primary care, 16 from secondary care and 30 from tertiary care. A semi-structured interview was applied using a pre-defined script and similarity analysis using the Interface of R pour les Analyses Multidimensionnelles de Textes et de Questionnaires software. Results: structurally, the maximum tree revealed the central core in the upper right quadrant, the first peripheral zone in the upper left quadrant; the second peripheral zone in the lower left quadrant; and the silent zone in the lower right quadrant. The ten branches of the maximum tree emerged from the following terms: hit, leave, approach (n), receive, approach (v), remember, tell, spend, pass, caution, mom. Conclusion: the social representations on the nurses’ approach in primary, secondary and tertiary care health services evidenced common points as for the lack of notification, transfer of responsibilities, weakness in identifying situations of violence and the need for training.


Introduction
Maltreatment of children and young individuals represent an international, national and regional reality affecting children and adolescents from different cultural, ethnic and social contexts (1) . This phenomenon is shown as a demand for health services around the world.
Currently, there is an urgent need for approaches with an integral and contextual view for these victims, requiring nurses' skills and expertise to manage these situations of violence (2) .
According to the World Health Organization (WHO), violence against children and adolescents consists of all forms of physical, emotional and sexual harm, abandonment, exploitation or neglect carried out by oppressive power relations affecting children's and adolescents' development and dignity (1) ; with the main forms of abuse being as follows: negligence, and physical, psychological and sexual abuse (3) .
In this scenario of child-youth vulnerability, eleven of the 18 Sustainable Development Goals (SDGs) and 19 of the 53 health-related SDG indicators are related to children's and adolescents' health; the protection of this vulnerable group being a global commitment of the international agencies; however, it is estimated that, globally, every year one out of two children aged from 2 to 17 years old suffer some form of violence; one third of the adolescents aged between 11 and 15 years old are bullied by their peers in schools and 120 million girls under the age of 20 have suffered sexual violence (4) .
In North America, the lifetime prevalence of sexual abuse is 20% for girls; and psychological/emotional violence is 28%; while in South America, the indicators show a high prevalence of neglect with numbers of 55% for girls and 57% for boys (4) . In the Brazilian scenario, interpersonal violence is the second or third leading cause of death among children and adolescents, depending on the region (5) . In the national scenario, in 2019, DISK 100 data indicated the occurrence of 17,000 reports of sexual violence against children and adolescents, with 73% of the cases taking place in the victim's home and 46% of the victims being female adolescents (12-18 years old) (6) .
Violence against children and adolescents is a public health problem of high priority; according to the WHO.
Among the seven strategies to combat violence against children and adolescents in the world, access to good quality health, protection and justice services stand out (7) . Thus, nurses have proved to be key elements in the prevention process, early identification and assistance of child-youth abuse (8) ; for this, it becomes necessary that such professionals raise suspicions regarding such cases in the various health services (9) . However, the nurses' role in coping with violence situations is still permeated by several challenges involving professional qualification during academic training and/ or permanent education at work, as well as difficulties in reporting the cases, need for protocols and care routines (10) .
A number of studies (11)(12)(13)(14)(15) point out relevant factors that permeate the intervention by nurses in cases of violence in the pediatric and adolescent population, such as the reason for the silence established in the family, the fear coming from the professionals for having doubts about tangible problem solving, definition of care protocols and flows, professional training, lack of resoluteness by the child protection agencies and lack of institutional and governmental support to deal with these families (16) .
From this perspective, apprehension of the convergences and divergences in the nurses' approach to children and adolescents who are victims of violence raises the need to understand the social representations of the nurses' performance in different health care settings.
The nurses' role in primary health care is marked by the bond with the communities, which, on the one hand, favors the identification of situations of violence and, on the other hand, causes fears and insecurities in the face of the cases (17) ; in the hospital service, nurses are in an emergency context with difficulties in correctly identifying and reporting abuse situations with children and adolescents (18) .
The theory of social representations is based on the analysis of socially elaborated and shared knowledge in specific processes of social interaction, which contributes to the formation of a common reality in a given social group, showing what is consciously shared with other members of the social group (19) .
However, there are still no research studies that reach the nurses' social representations (20) about their professional performance in the face of child abuse in order to qualitatively understand the elements that permeate the nurses' approach to these victims of violence considering the Brazilian organizational structure of health by levels of care and their specificities.
Based on this panorama of deficits in qualitative studies on nurses' management of child abuse, associated with the evident need for qualification in coping with these situations in the health services, scientific deepening of the relationships that permeate this professional practice is justified.
Given the above, the following question emerged: representations, under the Central Core Theory (CCT) (21) , considered as a central element of the nurses' performance in different health services in the care of victimized children and adolescents.
The objective was to analyze the social representations from the perspective of the structural aspect of the nurse's approach to children and adolescents who are victims of violence, comparing primary, secondary and tertiary health care services.

Type of study
An analytical research study with a qualitative approach was carried out under the methodological theoretical framework of the Theory of Social Representations (TSR) (22) based on the Central Core Theory (22) . The choice of such theory is justified in order to achieve translation of the meanings and values intrinsic to the nurses' work when approaching children and adolescents in situations of violence, as historically determined beings, immersed in a particular society and culture, with an emphasis on the Central Core in order to recognize the central essence of the nurses' approach at different health care levels.
Elaboration of the manuscript followed the COREQ (Consolidated Criteria for Reporting Qualitative Research) recommendations, meeting the scientific requirements for a qualitative study.

Research scenario
The research was designed in a municipality from the inland of northeastern Brazil, a reference for health care in the surrounding municipalities of the state of Paraíba.
In order to maximize the number of nurses working at the three levels of care for children and adolescents who are victims of violence, Family Health teams (FHts) were selected to cover primary care; a specialized hospital, for pediatric care representing secondary care; and a referral hospital, for trauma and violence at a regional level, in tertiary care.
At the time of data collection, there were 107 FHts in the municipality, distributed in 84 Basic Health Units (BHUs) and six Health Districts. The specialized hospital for pediatric care, which is characteristic of secondary care offering outpatient and specialized services, without high-complexity demand, stands out as the only pediatric hospital service in the municipality, with 25 nurses working in the reception, emergency and nursing sectors.
The tertiary level was represented by a reference hospital for trauma and violence at the regional level, which has the largest number of appointments related to serious situations of violence involving children and adolescents. There were 62 nurses distributed among the sectors: reception, red room, pediatric observation, pediatric ward and pediatric ICU.

Study participants and selection criteria
A total of 76 nurses selected by convenience participated in the study. The number of participants was determined by theoretical saturation (23) for the groups of nurses at the primary and tertiary levels and by exhaustion criteria for the professionals at the secondary level.    There were no refusals among the participants at the primary level, with one refusal in the secondary service and eight at the tertiary level associated with the dynamics of an intense work routine.

Procedures and data collection instruments
Data collection took place between January and

Data treatment and analysis
The data were processed using the IRAMuTeQ

(Interface by R pour les Analyses Multidimensionnelles de
Textes et de Questionnaires) software (24) , which enabled production of the maximum tree (similarity analysis).
Data organization for analysis in the software occurred, initially, by the construction of the textual corpus according For data analysis, the Theory of Social Representations was adopted as the methodological theoretical grounds, with emphasis on the Central Core Theory, which was considered a complementary approach to the first, considered, among others, as the structural aspect (21) .
Based on the premise that every social representation is organized around a central core associated with other complementary structural instances, the central core has the organizing function as a unifying and stabilizing element of the representation (25) .
Thus, the similarity analysis was performed as a technique for surveying the central core, which is considered the main technique for detecting the degree of connectivity between the elements of a representation and, consequently, defining the central core. Similarity analysis is one of the main analysis techniques to achieve the Social Representations.
The similarity analysis, via IRAMuTeQ, was based on the relationship between the number of co-occurrences and the number of subjects involved, establishing connections between these elements based on the graph theory; the graphic representation of the connections produces the maximum tree. The parameters for the construction of the maximum tree included the co-occurrence index and the descriptive variable highlighted in the graphic representation, which is the health care level (26) . In the maximum tree, code I represents the terms associated with PHC nurses; code II is the secondary care service and code III is the tertiary care service in each analytical axis; those terms without coding were not associated with any specific health care level. With the textual corpus organized, a similarity analysis was performed to obtain the maximum tree.
Subsequently, the excerpts of relevant speeches that agreed with the organization of the maximum tree regarding the approximations and distances of the nurses' social representations were selected.
Given the structuring of the Social Representations, provided by the similarity analysis associated with text segments from the nurses' speeches, Bardin's analysis of co-occurrences was constituted (27)

Ethical aspects
The research followed the ethical parameters of the

Results
Among the three levels of complexity, female nurses aged between 30 and 40 years old were predominant.
Most of the professionals in the first and third care level had more than 10 years since graduation, while those in the specialized service had between 5 and 9 years since having finished their studies. As for the specific

Discussion
Every social representation is structurally organized around a central core and a peripheral system with the existence of a silent zone; according to the author of the Central Core Theory (25) , this premise is constituted from Moscovici's grand theory itself. The central core is related to collective memory, which generates meaning, consistency and permanence to the representation; thus, it is characterized as stable and resistant to change, being fundamental for the meaning and organization of the representation (21) .
In this study, it is pointed out that the central core focuses on the approach to the child who is a victim of violence in the symbolic of the care process performed by nurses, revealing a strongly marked sense in the collective memory of these professionals associated with the child, which can be related to the intrinsic biopsychosocial vulnerability of the child age group, with adolescents in the background.
The central core assumes a meaning-and sense-generating function for the complementary elements (peripheral zone), as it highlights the values and meanings that permeate the behaviors performed by the nurses, presented in the peripheral area of the maximum tree (25) ; as well as an organizing function that determines the nature of the connections established between the elements of the representation.
In this sense, the elements that characterize the particularities of approaching victims of violence at the different health care levels are explored in the peripheral and silent zone. In the peripheral system, elements common to the nurses who worked at the three health care levels are evidenced; however, the particularities of the nurses' behavior are also revealed, related to the health service in which they work. Therefore, it is in the peripheral system that the heterogeneity of the representations of the groups is allocated, supporting the contradictions and individual histories in a contextualized manner (21) .
In the peripheral system, the nurses' differentiated practices in approaching children and adolescents who are victims of violence were identified. In primary health care, the approach to these victims has specificities, considering that most of them suffer situations of violence in the domestic environment; knowing and monitoring the families proves to be an essential factor in approaching the cases (28) .
This interaction with the family permeates the entire multi-professional team, with emphasis on the Community Health Agents, who, through direct contact with the families, can produce early detection and the establishment of a link with the Basic Health Units that act as a reference and support for the communities (28)(29) .
A study points out the strength of PHC in confronting in Basic Health Units (30)(31)(32) .
The childcare consultations, for being a routine in the nurses' work process in the BHUs, are shown as the tool for greater access for nurses to aspects of comprehensive child care, as they involve assessment of growth and development, immunization, feeding, specific hygiene care and prevention of accidents, including prevention and identification of situations of violence (33) .
Adolescents' health care has not received assistance in the same proportion, according to the deficit highlighted in the National Adolescents' Health Survey (34) ; in it, it was identified that only 48% of the adolescents sought some health service or professional in the last 12 months of the research. Access barriers can hinder this search, such as lack of knowledge about health services or discomfort in sharing health concerns, in addition to the way in which the health teams welcome these adolescents (34) .
An important element in producing close relationships between children/adolescents and the Family Health teams comprises the practice of health promotion actions in the spaces of the school, the community and the BHU itself (35) . In carrying out these actions, the nurse builds the opportunity to encourage a culture of peace, healthy affective relationships and prevention of violence (36) by identifying risk situations based on the proximity to the children and adolescents.
In the secondary care health service, the care focus is based on the medical-centric approach to violence, centered on the biological body, disregarding subjective, psychological and social aspects (37) ; although there is a physical and organizational space for the production of care for the victim by the nurse, at this health care level, this practice does not effectively occur as an opportunity for qualified and expanded listening (38) . identifying violence against this group (10) .
In tertiary care, the focus on the conduct-complaint maintains the hospital-centered view of nurses towards victims of violence, with assistance aimed at remedying the demands of physical urgencies and emergencies. By displaying a behavior focused on the victim's physical weakness, a number of studies show that emergency services do not recognize, screen or report situations of violence, since the professionals in the emergency rooms are not aware of this phenomenon (39)(40) .
When it comes to violence against children and as in the hospital environment, by noticing signs that are not exposed or revealed, especially in the emergency services, a space for greater assistance to child abuse (9) .
The identification of child-youth abuse appears as difficulty and inhibits notification of these cases, as shown by a study conducted in Saudi Arabia (14) . Identifying To produce an approach aimed at the victims' needs, technical-scientific knowledge is required; the study highlights the notorious fragility of professional training by nurses to approach children and adolescents in situations of violence, which corroborates a recent study (44) involving physicians, nurses and dentists and other studies (14,(45)(46) that highlight lack of knowledge and the need for training as important barriers to identifying physical abuse with children and adolescents.
This context is a reflection of academic training and insufficient encouragement to train professionals and to define flows and care protocols in the health services, which exerts a direct impact on the feelings expressed by the nurses in the face of cases of violence, as well as on the service performed (10,16,41) .
Professional training of nurses to deal with cases of violence with children and adolescents emerged in the silent zone, which corresponds to a subset of meanings, beliefs and cognitions, which, even though they exist, are not expressed in the usual conditions due to the values and norms of the group itself (25) . The weakness in the nurse-related training regarding the issue in question is found in the work context; however, in the daily practice, the nurse is socially and institutionally required to provide care, regardless of this subsidy.
Nursing care in conjunction with the multidisciplinary team is characterized as another challenge, marking In the meantime, the study highlights ways to qualify the nurses' approach to children and adolescents who are victims of violence in the health services by indicating the weaknesses of each health care level and the specific points of possible interventions from the organization of the work process, instruments of action and training for the nurses' practice in managing the health services.
As study limitations, the smaller number of nurses who worked in the red room of the emergency health service can be mentioned, as a result of the particularities of the sector's routine; as well as some health professionals' difficulty opening to discuss the theme of violence and the praxis itself in dealing with these cases.
The starting point is the premise that there are different ways of knowing and communicating violence to children and adolescents, guided by different objectives of the nurses at the three care levels, ways that are mobile and in which two of them can be defined, in terms of handling or acting on them, which, in turn, are urgent in our societies: the consensual and the scientific (22) . In this sense, each nurse, according to the health care level in which they work, generates their own representational universe of violence; this fact, which is situated as a modality of particular knowledge, which has as its function to develop behaviors and communication between individuals in a society that produces meanings (22) .
It can be highlighted that the study object permeates the information scaled by the TSR, such as the information, the field of representation and the professional's attitude towards the complex and polysemic phenomenon of violence against children and adolescents, since that the similarity analysis allows approximating knowledge about the phenomenon using pressure to inference, engagement and information (22) .

Conclusion
The primary, secondary and tertiary health care Instrumentalization of the Nursing practice through guidelines, protocols, flowcharts and technical-scientific deepening becomes essential for an effective and precise performance that shall fully meet the victims' needs.