ARTÍCULO ORIGINAL / ORIGINAL ARTICLE / ARTIGO ORIGINAL
Interdisciplinary action of nurses to children with suspected sexual abuse
Trabajo interdisciplinar del enfermero con el niño con sospecha de abuso sexual
Ação interdisciplinar do enfermeiro à criança com suspeita de abuso sexual
Lia Leão Ciuffo1; Benedita Maria Rêgo Deusdará Rodrigues2; Florence Romijn Tocantins3
1RN, Ph.D. candidate. Professor, Escola de Enfermagem Anna Nery da Universidade Federal do Rio de Janeiro, Brazil. email: firstname.lastname@example.org.
2Enfermeira, Doutora. Professora, Universidade do Estado do Rio de Janeiro, Brazil. mail: email@example.com.
3Enfermeira, Doutora. Professora, Escola de Enfermagem Alfredo Pinto da Universidade Federal do Estado do Rio de Janeiro, Brazil. email: firstname.lastname@example.org.
Receipt date: Jun 5, 2013. Approval date: Oct 7, 2013.
Article linked to research: "Assistência do Enfermeiro à criança com suspeita de abuso sexual" aprovado no Programa de Pós Graduação da Faculdade de Enfermagem da Universidade do Estado do Rio de Janeiro.
Conflicts of interest: none.
How to cite this article: Ciuffo LL, Rodrigues BMRD, Tocantins FR. Interdisciplinary action of nurses to children with suspected sexual abuse. Invest Educ Enferm. 2014;32(1): 112-118.
Objective. Understanding the role of nurses as members of interdisciplinary teams in the care of children with suspected sexual abuse. Methodology. This is a qualitative research based on the sociological phenomenology of Alfred Schutz. In 2008 were interviewed eleven nurses who worked in reference institutions for the care of child victims of sexual abuse in Rio de Janeiro. Results. The category called 'Interacting with other professionals in child care' emerged from the analysis of performance of professionals. The intersubjective relations between the nurses and the interdisciplinary team will enable to understand the intent of care from the perspective of social, emotional and psychological needs of children and their families. Conclusion. Interdisciplinarity favored the development of actions based on acceptance, listening and agreements on possible solutions in the care of children with suspected sexual abuse.
Key words: nursing; sexual child abuse; patient care team.
Objetivo. Comprender la actuación del enfermero como integrante del equipo interdisciplinar en la atención del niño víctima de abuso sexual. Metodología. Investigación cualitativa con base en la fenomenología sociológica de Alfred Schutz. En 2008 fueron entrevistados once enfermeros que laboraban en instituciones de referencia del Estado de Rio de Janeiro para la atención de niños víctimas de abuso sexual. Resultados. Del análisis de la actuación profesional emergió la categoría "Interactuar con otros profesionales en la atención del niño". Las relaciones intersubjetivas entre el enfermero y el equipo interdisciplinar le posibilitan comprender la intencionalidad del cuidado desde la perspectiva de las necesidades sociales, emocionales y psicológicas del niño y su familia. Conclusión. La interdisciplinariedad favoreció el desarrollo de acciones basadas en la aceptación, la escucha y el acuerdo sobre las posibles soluciones en la atención del niño víctima de abuso sexual.
Palabras clave: enfermería; abuso sexual infantil; grupo de atención al paciente.
Objetivo. Compreender a atuação do enfermeiro como integrante da equipe interdisciplinar no atendimento da criança com suspeita de abuso sexual. Metodologia. Investigação qualitativa com base na fenomenologia sociológica de Alfred Schutz. Em 2008 foram entrevistados onze enfermeiros que laboravam em instituições de referência do Estado de Rio de Janeiro para o atendimento de crianças vítimas de abuso sexual. Resultados. Da análise da atuação profissional emergiu a categoria "Interagir com outros profissionais no atendimento da criança". As relações intersubjetivas entre o enfermeiro e a equipe interdisciplinar lhe possibilitam compreender a intencionalidade do cuidado desde a perspectiva das necessidades sociais, emocionais e psicológicos da criança e sua família. Conclusão. A interdisciplinaridade favoreceu o desenvolvimento de ações baseadas na aceitação, a escuta e o acordo sobre as possíveis soluções no atendimento da criança com suspeita de abuso sexual.
Palavras chaves: enfermagem; maus-tratos sexuais infantis; equipe de assistência ao paciente.
Child sexual abuse is a complex phenomenon that must be investigated in depth and examined with caution. This type of violence often leaves no visible marks, hindering the assistance from professionals involved in the care of children and their families, including nurses. Sexual violence is a crime and can be defined as any act in which a person, through physical force or psychological intimidation, causes another to perform sexual act against their will.1 It can be difficult to diagnose this type of abuse, considering that the perpetrator is a family member and the child physically and psychologically depends on the perpetrator of the violence.2 Regarding the perpetrators of child sexual abuse, it was identified that the main ones are the companions of mothers, followed by biological parents, grandparents, uncles, godparents, as well as mothers, grandmothers, aunts and others who have with the child a relationship of dependence, affection or trust, in a context of incestuous relationships.2 In other words, the aggression remains hidden because of the prevailing fear of being punished by the offender.3 Thus, one of the most critical points of this alarming issue in our society is that the child often becomes the victim of this assault for a long time, indelibly marking their mental and social health.
In this perspective, when assisting the child, it is advisable that the nurse provides a humanized service, with foundation in scientific knowledge and in reliance on the Statute of Children and Adolescents (Estatuto da Criança e do Adolescente4) aiming at an appropriate care both for children and their families. At the same time, it is essential to articulate and link with other disciplines, areas of knowledge and care practices in order to understand and address the needs of human beings - their social and health needs - in a more comprehensive and holistic manner.
The proposal of interdisciplinary work in the field and practice of health points to a path of expansion of possibilities for a more effective action for these children and their families. Thus, when nurses seek partnerships with other disciplines and areas of knowledge, their field of vision and action can be expanded as they gain access to new knowledge that can be aggregated and thought within a group of professionals from diverse backgrounds, focusing on such a current and relevant topic as sexual violence. In this sense, it is worth noting that interdisciplinarity aims at the concern with the attitudes, behaviors and lifestyle of people. Its theoretical work can be considered important in the field of public health.5
A good communication between healthcare professionals enables alliances between teams, what adds new perspectives and builds knowledge, and also reflects in the relationship of professionals with clients.6 Thus interdisciplinarity points to a path of integration among health professionals. From this line of reasoning was drawn the objective of this study: understanding the action of nurses as members of interdisciplinary teams in the care of children with suspected sexual abuse. The presented study is in the context of issues involving human life and contributes to the comprehension and interpretation of the actions of nurses and the relationship they establish with different professional areas in the benefit of the health and welfare of children.
A qualitative research based on the theoretical and methodological approach of social phenomenology of Alfred Schutz,7 and grounded on the search for the meaning of the action from the intentional consciousness of the involved subjects. The term 'action' defines human behavior as an intentional ongoing process that is perceived by the actor and that is based on a pre-designed project. Thus only the subjects themselves may be responsible for defining the meaning of their actions. Perceiving the nature of actions that involve attitudes adopted in the daily practice of nurses who deal with children with suspected sexual abuse is a process that occurs through contact with these children. Therefore in order to understand the actions of nurses, it is necessary to apprehend the meaning of their actions in the world of everyday life that takes place in the institution setting of their practice, which somehow indicates a way of being professional.
The world of life means the world of intersubjectivity, which has always existed, was experienced and interpreted by others and by our predecessors as an organized world. So, one can say that the interpretations of each subject pervade their own life experiences, combined with the amount of knowledge acquired through the teachings of family, teachers, and people with whom we deal directly and indirectly. Subsidized by the conceptions of social phenomenology, it is important to understand the interaction of nurses in their professional and social lives and especially, in actions of intersubjective nature with the interdisciplinary team. Intersubjectivity occurs when humans relate through their subjectivity, leading them to common influences, understanding others and being understood by them.7
The subjective nature of the intentional action is endowed with purpose when the social actor, also as the author of an action, materializes a certain conduct. With this understanding, the social phenomenology of Alfred Schutz brings the concepts of reason for and reason why of the actions developed in the world of life. The reason for of the action implies understanding the process of the ongoing action with the perspective of the future. On the other hand, the conception of the reason why refers to already undertaken actions and, as such, is guided by past experiences and recognized as conditioning the performance of the actor regarding the action in question.7 In accepting this view it is possible to affirm that the phenomenology of Schutz interweaves the meanings of subjectivity, intersubjectivity and intentionality of the consciousness of the author of the action. For this purpose it is necessary to enter the world of the life of the subject-author in order to seek the understanding of the meaning of established human relations.8
Trajectory of the study: considering the formal ethical aspects, the study was approved by the Ethics Committee in Research of the Municipal Health Secretariat of Rio de Janeiro under number 207/07 on December 17th, 2007. The studied social reality involved the professional setting of nurses who assist children with suspect of having been sexually abused. This option was due to the understanding that it is essential to consider the context in which the subject-authors are inserted to apprehend the meaning of their actions as something intended to achieve a particular purpose. In this sense, the subjects of this study were nurses in a Municipal Hospital located in the State of Rio de Janeiro that is also a reference institution for the care of children who are victims of sexual abuse. It is noteworthy that nurses who met the inclusion criterion of assisting children suspected of having been sexually abused were invited to participate in the study voluntarily and anonymity was guaranteed in the presentation of results. The technique of unstructured interview was used as a strategy to access the experiences and actions of nurses, including a phenomenological question that enabled capturing the meanings of their actions. The interviews were carried out in the first semester of 2008.
The contents of the interviews were recorded with the permission of the nurses and the following guiding questions, were used (among others): What do you do when assisting a child with suspected sexual abuse? What do you bear in mind with the nursing actions triggered in this type of care? Initially the number of respondents was not determined. However, from the moment the content of the answers to the phenomenological question - What do you bear in mind with the nursing actions triggered in this type of care? - became repetitive and without variations, and consequently leading to the saturation of the findings of the reason for expressed in speeches, the interviews were closed.
A total of 11 nurses participated in the study, five of them working on a daily shift basis and six of them covering shifts. It is noteworthy that two of them worked in the pediatric clinic and the other nine in the pediatric wards and at each meeting for the interviews between 20 to 45 minutes were used. A codename was given to each respondent nurse (Portuguese name of a large canopy tree, randomly selected) in order to preserve the confidentiality of their identity, and thus comply with an essential aspect of ethical research. The stage of analysis of speeches was carried out from the careful and separate reading of the speech contents of each respondent in order to apprehend how the studied objects manifest themselves. Thus, it was possible to group similar aspects aiming at categorization. And finally the meaning expressed by the nurses who serve children with suspected sexual abuse was built.9,10
Four categories emerged from the research, which were given the following titles: Interacting with other professionals in child care; Establishing communication and an open listening; Care from the perspective of others and; Assisting children while fulfilling the routines of the unit. Considering the focus of this study, we highlighted the concrete category of the experiences with content characteristics that point to "Interacting with other professionals in child care". This category emerged from the speeches of the subjects and it shows the relevance of interdisciplinary actions in the relationships established by nurses aiming at comprehensiveness of care and attention to children with suspected sexual abuse. Following are some excerpts that point to/show the intention of the action of the subjects - nurses in this sense: [...] Referrals to talk to pediatricians so they can work on this issue and find out if it is a closed thing. By the time we refer to the DIP, or for social services ... From that point we will not get involved. – JACARANDÁ; There are referrals, and who does that are the doctors. So we talk and they make a referral or for mental health [...]. – JEQUITIBÁ; In the level of nursing actions one can make referrals to the psychology and call the mother or responsible person to talk and find out what is going on. – ABÓBADA.
It is possible to verify that the actions of the nurse-respondents imply a belief about the importance of having an interaction among the disciplines and different professional categories with regard to sexual violence committed against children: [...] If it is proved that the father was abusive there is another step: one has to inform and notify the Guardian Council through social services and also in other cases of abuse. - IPÊ-ROXO; [...] the nursing team already has a look directed to cases of abuse and carefully provides assistance along with the psychology team, social services and the doctors and then, unfortunately, when the legal issue will be resolved we lose that bond with the child. – FLAMBOYANT; [...] the screening is done by the nurses and then we refer to the doctor. - SETE- COPAS.
At the same time the nurses-subjects of the action make it clear that their world of professional life is permeated by intersubjective relationships with the interdisciplinary team in the care provided to children: [...] we ask the psychologist and social worker for help. I think it's important to arrange meetings so every professional can see what's within their reach in order to help ... if we have professionals who have already walked this path we have to ask them... – QUARESMEIRA; So I think we have to make referrals to social services because they are the ones who make referrals to the Guardian Council and in my point of view this flow is important, right? – OITI; Discussing the causes of sexual abuse ... creating mechanisms, strategies to be able to notify and to know how to work with the realities of a hospital, but also with a PSF of a basic unit. - MAGNÓLIA AMARELA; The moment you receive an information, you evaluate it and see if there's any data, anything else that can collaborate with the final conclusion, ie, one must always be interacting with the team. - IPÊ –ROXO.
Given the highlighted results, we believe that interdisciplinarity consists of important possibilities of providing comprehensive care and full attention to children with suspected sexual abuse. It is noteworthy that the interdisciplinary action of the nurse involves referrals to (among others): doctors so they can make their review; social workers who, in this scenario, are the professionals responsible for notifying and informing the Guardian Council; and for psychologists, who follow-up and monitor mental health issues.
The nurses emphasize that a step of great importance in the care for children with suspected sexual abuse is to interact with other professionals in child care. With this understanding, referrals to doctors, social workers and psychologists express strategies and institutional paths to be followed in child care. The actions taken by the nurse as a member of the interdisciplinary team emphasize the reason for of the action, which is intended to carry out a project aiming at reaching a goal.7 Thus it is clear for the nurses that joining forces with other professionals to provide comprehensive care - more global, complete and focused on social, emotional and psychological needs - enables higher quality of care, which characterizes the contribution of professionals from diverse backgrounds in the assistance. Thus the availability of an interdisciplinary team that ensures the medical, psychological and social support needed for victims and their families, from the perspective of nurses is an important measure to ensure the right to an adequate and comprehensive care. With this understanding and in order to provide assistance for difficult cases to manage in the health units, the Ministry of Health2 points out that referral services should be established taking as example care services to victims of sexual abuse and their families.
It can also be observed that the nurses explain the importance of the interaction with other professionals during the assistance, searching for better solutions for their actions and thereby gaining a support and acquiring new knowledge. So the motives and reasons for the actions of the subjects have to be understood, as well as the acquisition of knowledge in the context in which they are inserted.7 Valuing the professional and interdisciplinary actions is vital to offer adequate support. The efforts should focus not only on physical examination and diagnosis, but also on the emotional and psychological support for the well-being of children.11 This issue can be justified by the fact that the victimized child is very vulnerable, and therefore it becomes important to go beyond the technical care, also providing subjective care and bearing in mind that the latter is permeated by the uniqueness and individuality of each child and by the way their feelings and emotions are expressed.12 In this context, it is worthwhile mentioning that a study on labor relations in interdisciplinary teams13 showed the existence of several factors that influence the improvement of the relationship between professionals and clients. The highlights among them are: bonding, user embracement and humanization.
Supported by this line of thought, it is also noteworthy14 the relevance of the incorporation of interdisciplinarity in the nursing curriculum, through a gradual structuring in thematic areas that can be inserted both as complementary activities and in the spheres of health care operations of the Brazilian Unified Health System. Undoubtedly it is important to take the interdisciplinarity into account, both in training and in the development of professional skills, based on new paradigmatic structures. At the same time there is the procedural nature of its construction that requires space and opportunity of disciplinary encounters in different settings of care, teaching and research.
Final considerations. As violence is a phenomenon of the lived past, it requires effective actions in order to be reduced. Information, education and notification to the competent organs are key elements to guide the actions of the professionals who deal directly with children. So it is necessary to think about the development of a solid scientific knowledge that can guide health practices of nurses and health professionals who deal with the reality of violence against children.
The results of this study show the importance of the relationship between nurses and the health care team. Therefore, interdisciplinarity plays an important role when it comes to care of children with suspected sexual abuse, considering that it provides communication, interconnections of experiences and it establishes a flow of information and scientific expertise of various professionals. Thus, the actions taken by the nurses as members of the interdisciplinary team pass for the interaction with professionals in the health team. Established intersubjective relationships stimulate the way of acting of the nurses, who in turn have the ability to share, expand and solidify their knowledge in the area. Moreover, interdisciplinarity favors the development of actions based on user embracement, listening and agreement on possible solutions in care for children with suspected sexual abuse. Finally, we hope this study can encourage the deepening of other studies on the perspective of violence against children in order to assist in reflections on nursing actions when faced with this social problem.
1. Brasil. Ministério da Saúde. Secretaria de atenção à Saúde. Por uma cultura de paz, a promoção da saúde e a prevenção da violência. Brasília (DF): Ministério da Saúde; 2009.
2. Brasil. Ministério da Saúde. Secretaria de atenção à Saúde. Linha de cuidado para a atenção integral à saúde de crianças, adolescentes e suas famílias em situação de violências: orientação para gestores e profissionais de saúde. Brasília (DF): Ministério da Saúde; 2010.
3. Ciuffo L, Rodrigues B,Cunha J. [The nurse in sexual abuse child suspicion attention: a phenomenology approach] Online Brazilian Journal of Nursing [Internet]. 2009 [Cited 2012 February 28]; 8(3). Portuguese. Available from: http://www.objnursing.uff.br/index.php/nursing/article/view/2665.
4. Brasil. Ministério da Justiça. Estatuto da Criança e do Adolescente. Texto Reduzido. Brasília (DF): Ministério da Justiça; 1990.
5. Luz MT. Complexity of collective Health Field: Knowledge and practice multidisciplinarity, interdisciplinarity and transdisciplinarity - a paradigmatic trajectory socio-historical analysis. Saúde Soc. 2009;18(2): 304-311.
6.Canela P, Maldonado MT. Recursos de relacionamento para profissionais de saúde: a boa comunicação com clientes e seus familiares em consultórios, ambulatórios e hospitais. Ribeirão Preto, SP : Novo Conceito; 2009.
7. Schutz A. El problema de la realidad social. 2nd reimp. Buenos Aires: Amorrortu; 2008.
8. Almeida IS, Ribeiro IB, Rodrigues BMRD, Da Costa CCP, Freitas NS, Vargas EB. Breastfeeding for primiparous mothers nurse's perspectives and intentions while orienting. Cogitare Enferm. 2010; 15(1):19-25.
9. Rodrigues BMRD. O Cuidar de Crianças em Creche Comunitária: contribuição da sociologia fenomenológica de Alfred Schutz. Londrina: UEL; 1998.
10. Tocantins FR. As necessidades na relação cliente-enfermeiro em uma unidade básica de saúde: uma abordagem na perspectiva de Alfred Schutz. [Dissertation]. Rio de Janeiro: Universidade Federal do Rio de Janeiro; 1993.
11. Rossi CS, Rodrigues BMRD. Characteristics of professionals of nurses regarding the care provided by family members of hospitalized children. Acta Paul Enferm. 2010 ; 23(5):640-5.
12. Woiski ROS, Rocha DLB. Nursing care for sexually abused children in hospital emergency units. Esc. Anna Nery . 2010; 14 (1): 143-50.
13. Matos E, Pires DEP, Campos GWS. Work relationships among interdisciplinary teams: contributions for new methods of organization in health work. Rev Bras Enferm 2009; 62(6): 863-9.
14. Galindo MB, Goldenberg P. [Interdisciplinarity in Nursing Diploma Programs: na evolving process] Rev. bras. enferm 2008; 61(1):18-23. Portuguese. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-1672008000100003&lng=en&nrm=iso.