Nursing care for child/adolescent victims of violence: integrative review

R E V I S T A O N L I N E D E P E S Q U I S A CUIDADO É FUNDAMENTAL UNIVERSIDADE FEDERAL DO ESTADO DO RIO DE JANEIRO . ESCOLA DE ENFERMAGEM ALFREDO PINTO INTEGRATIVE REVIEW OF THE LITERATURE DOI: 10.9789/2175-5361.rpcfo.v12.7102 NURSING CARE FOR CHILD/ADOLESCENT VICTIMS OF VIOLENCE: INTEGRATIVE REVIEW Assistência de enfermagem à criança/adolescente vítima de violência: revisão integrativa Asistencia de enfermería al niño/adolescente víctima de violencia: revisión integrativa Manoella Souza da Silva1, Viviane Marten Milbrath2, Bruna Alves dos Santos3, Jéssica Stragliotto Bazzan4, Ruth Irmgard Bartschi Gabatz5, Vera Lúcia Freitag6 How to cite this article: Silva MS, Milbrath VM, Santos BA, Bazzan JS, Gabatz RIB, Freitag VL. Nursing care for child/adolescent victims of violence: integrative review. Rev Fun Care Online. 2020 jan/dez; 12:115-123. DOI: http://dx.doi.org/ 10.9789/2175-5361.rpcfo.v12.7102. ABSTRACT Objective: to explore the literature regarding the nursing care provided to children/adolescents victims of violence. Method: it consists of a systematic review performed on databases such as, LILACS, Scielo and BDENF. 19 articles have been selected to compose this study. The data analysis was developed throughout Mendes, Silveira and Galvão’s proposal. Results: the data discussion occurred throughout the following topics: professional unpreparedness to deal with cases of child violence; the feelings of professionals involved on the care provided to a child/adolescent victim of violence; notification, protocols and routines regarding the assistance of children/adolescents victims of violence. Conclusion: nursing professionals do not feel prepared to deal with situations of children violence. It was identified the need of protocols that support the nursing assistance. Furthermore, it is important to enhance the intersectoral attention network in order to ensure the appropriate care to the victims and their families. Descriptors: Nursing; Violence; Child; Adolescent. 1 Nursing Graduate by the Universidade Federal de Pelotas, Registered Nurse at Ambulatório União (Pelotas/RS). 2 Nursing Graduate by the Universidade Federal de Pelotas, MSc in Nursing by the Universidade Federal do Rio Grande, PhD in Nursing by the Universidade Federal do Rio Grande do Sul, Adjunct Professor at Universidade Federal de Pelotas. 3 Nursing Graduate by the Universidade Federal de Pelotas, Registered Nurse at Hospital Tacchini (Bento Gonçalves/RS). 4 Nursing Graduate by the Universidade Federal de Pelotas, MSc in Nursing by the Universidade Federal de Pelotas, PhD Student in Nursing at Universidade Federal de Pelotas, Registered Nurse at Hospital São Francisco de Paula (Pelotas/RS). 5 Nursing Graduate by the Universidade Federal do Rio Grande do Sul, Post-Graduate in Hospital Administration by the Universidade do Sul de Santa Catarina, MSc in Nursing by the Universidade Federal de Santa Maria, PhD in Nursing by the Universidade Federal de Pelotas, Adjunct Professor at the Universidade Federal de Pelotas. 6 Nursing Graduate by the Universidade Federal de Santa Maria, Specialist’s Degree in Public Health Management by the Universidade Federal de Santa Maria, MSc in Nursing by the Universidade Federal de Pelotas, PhD Student in Nursing at Universidade Federal do Rio Grande do Sul. DOI: 10.9789/2175-5361.rpcfo.v12.7102 | Silva MS, Milbrath VM, Santos BA et al. | Nursing care for child/adolescent... J. res.: fundam. care. online 2020 jan/dez 12: 115-123 115 ISSN 2175-5361 Silva MS, Milbrath VM, Santos BA et al. RESUMO Objetivo: desvelar a produção acerca da assistência de enfermagem prestada às crianças/adolescentes vítimas de violência. Método: trata-se de uma revisão sistematizada realizada com consulta nas bases de dados: LILACS, Scielo e BDENF. Foram selecionados 19 artigos para compor este trabalho. A análise de dados deu-se por meio da proposta de Mendes, Silveira e Galvão. Resultados: os dados foram discutidos através dos tópicos: despreparo dos profissionais frente aos casos de violência infantil; sentimentos dos profissionais envolvidos no cuidado à criança/adolescente vítima de violência; notificação, protocolos e rotinas na assistência à criança/adolescente vítima de violência; estratégias de assistência à criança/adolescente vítima de violência. Conclusão: os profissionais de enfermagem não se sentem preparados para atuarem frente aos casos de violência infantil. Identificou-se a necessidade de protocolos assistenciais que respaldem a assistência profissional. Ademais, é importante o fortalecimento da rede de atenção intersetorial que garanta a assistência adequada às vítimas e suas famílias. Descritores: Enfermagem; Violência; Criança; Adolescente. RESUMÉN Objetivo: desvelar la producción acerca de la asistencia de enfermería a los niños/adolescentes víctimas de violencia. Método: se trata de una revisión sistematizada realizada con consulta en las bases de datos: LILACS, Scielo y BDENF. Se seleccionaron 19 artículos para componer este trabajo. El análisis de datos se dio através de la propuesta de Mendes, Silveira y Galvão. Resultados: los datos fueron discutidos através de los tópicos: despreparo de los profesionales frente a los casos de violencia infantil; sentimientos de los profesionales envolvidos en el cuidado al niño/ adolescente víctima de violencia; notificación, protocolos y rutinas en la asistencia al niño/adolescente víctima de violencia; estrategias de asistencia al niño/adolescente víctima de violencia. Conclusión: los profesionales de enfermería no se sienten preparados para actuar frente a los casos de violencia infantil. Se identificó la necesidad de protocolos asistenciales que soporten la asistencia profesional. Además, es importante el fortalecimiento de la red de atención intersectorial que promueva la asistencia adecuada a las víctimas y sus familias. Descriptores: Enfermería; Violencia; Niño; Adolescente. INTRODUCTION Violence is defined by the World Health Organization (WHO) as the intentional use of physical force or power against oneself or against other persons, groups and communities that results in physical injury, psychological or developmental damage and/or death. Thus, child violence has become a serious public health problem in Brazil and the world, presenting itself in different ways and different contexts, regardless of social class, generating severe impacts on quality of life and high levels of morbidity and mortality among children/adolescents.2 It is the third leading cause of death in the general population and is one of the main causes of morbidity and mortality in children and adolescents.3 Each year the number of new cases reported is increasing, most of which occur in the home environment and the aggressor is a person with strong ties to the victimized child.4 In 2011, approximately 39 thousand cases of children/ adolescents aged between one and 19 years old were registered in the scope of the Unified Health System, referring to cases J. res.: fundam. care. online 2020 jan/dez 12: 115-123 DOI: 10.9789/2175-5361.rpcfo.v12.7102 Nursing care for child/adolescent... of violence. The most prevalent age group among notifications is under one year of age, followed by adolescents between 15 and 19 years.5 WHO reports that around 25% of the adult world population reported being abused in childhood.6 Therefore, children/adolescents are among the groups most likely to have their rights violated and to suffer physical, psychological and emotional abuse. So, health services should prioritize attention to these subjects to guarantee their quality of life.7 Considering this framework, nursing plays a fundamental role in assisting the victimized children/adolescents, considering that these professionals assume a privileged position within the multidisciplinary team, being in direct contact with the children/adolescents and their families and strengthening the bond between professional and user. Thus, nursing provides space that facilitates the identification of indicative signs of child violence, allowing them to act to minimize the recurrent damage of abuse, as well as to prevent the perpetuation of child and adolescent violence.8 Thus, this study aims to unveil the scientific production about nursing care provided to children/adolescents victims of violence. METHODS It is an Integrative Review, used to establish a careful evaluation that enables the systematization of scientific knowledge, bringing the researcher closer to the problem and allowing him to observe the evolution of the theme over the years.9 Thus, it allows the synthesis as well as the applicability of significant results in practice.10 This review was developed following six steps: identification of the theme and selection of the hypothesis or guiding question of the research; establishment of criteria for inclusion and exclusion of studies; definition of the information to be extracted from the selected studies; evaluation of studies included in the review; interpretation of results and presentation of the review and synthesis of knowledge.11 The guiding question was defined as: “What has been produced in the last ten years about nursing care for children/ adolescents victims of violence?”. Included in the review were studies conducted with humans, published in full between 2007 and 2016 in the English, Portuguese and Spanish languages, which, regardless of the design, addressed the highlighted theme, being available in the Literatura LatinoAmericana e do Caribe em Ciências da Saúde (LILACS) [Latin American and Caribbean Literature in Health Sciences], Base de Dados de Enfermagem (BDENF) [Nursing Database] and the Scientific Electronic Library Online (SciELO). Studies that did not answer the study question were excluded, as well as theses, dissertations, monographs, literature reviews, case studies, catalogs and letters to the editor. For the articles selection, the descriptors child abuse, nursing; and in a second phase, child, violence, nursing, which were previously consulted in the Health Sciences Descriptors (DeCS). It is noteworthy that “AND” was used between the descriptors as a Boolean Operator. 116 ISSN 2175-5361 Silva MS, Milbrath VM, Santos BA et al. DOI: 10.9789/2175-5361.rpcfo.v12.7102 Nursing care for child/adolescent... The database was consulted during September 2016. During the data collection, it was classified for better understanding of the integrative review, aspects considered relevant as the type of publication; methodology and sample, place and year of publication and results presented. This method has allowed to individually evaluate the studies, facilitating the identification of similarities and differences between them. The results are presented descriptively, through tables, to understand the nursing care provided to children/ adolescents victims of violence. After combining the aforementioned descriptors and applying the defined criteria, a total of 70 articles were found in the LILACS database. From this total, 28 studies were excluded because the title did not address the proposed theme, and seven because it was a literature review, leaving a total of 35 studies for a full reading. After reading, 19 studies were excluded because the results did not answer the guiding question. Thus, 16 articles were selected from the LILACS database to compose this study. In BDENF, 47 articles were found, 12 of which were excluded because the title did not address the proposed theme, nine because they were a literature review and 10 because were duplicated with the other databases. Thus, 16 studies were selected for full reading, after reading 15 studies were excluded because the results did not answer the guiding question, leaving one study to compose this review. In SciELO, a total of 35 articles came about, from those, 18 articles were excluded by the title not addressing the proposed theme, three for duplicity with the LILACS database and two because it is a literature review, leaving 12 articles for a full reading. After reading, 10 studies were excluded because the results did not answer the guiding question, leaving two articles to compose this study. Hence, 19 articles have totalized the review. RESULTS AND DISCUSSION For a better understanding of the included studies, tables 1 and 2 show the characterization of the studies included in this review. The language of the articles found was mostly Portuguese. All studies were conducted in Brazil, with the majority of participants being only nursing professionals, while the others were conducted with all professionals of the multidisciplinary team. Regarding the location of the research, Basic Health Units(2,4,7,13,21,22,25), Emergency Care and Pediatrics Units(18); Emergency Care Units(24); Urgency and Emergency Units(15); Pediatric Urgency and Emergency Units(16); Reference Institutions for child victims of sexual abuse(8,14); Emergency Units, Intensive Care or Pediatric Inpatient Care(26); Hospital Units(19,20,23); Residential Shelters(17); and Health Services, Hospitals and Child and Adolescent Protection Bodies(27). Concerning the methodological approach, most of the analyzed studies used qualitative approach, the rest used quantitative approach. Data collection was performed through semi-structured interviews(2,7,8,13,14,15,16,18,24,25,26,27); semi-structured interview, document analysis and observation(22); focus group(17); web format instrument(4); and previously structured form(19,20,21,23). In reference to the year of publication of the studies, eight articles were published between 2006 and 2010 and ten between 2011 and 2016. Table 1 - Identification of the studies. Research Type of study Evidence level.12 1 As possibilidades de enfrentamento da violência infantil na consulta de enfermagem sistematizada [Possibilities for addressing child abuse in systematized nursing consultation].4 Qualitative study Level VI 2 Abordagem dos casos de violência à criança pela enfermagem na atenção básica [Primary care nurses’ approach to cases of violence against children].7 Qualitative study Level VI 3 Violência intrafamiliar contra a criança: intervenção de enfermeiros da Estratégia Saúde da Família [Family violence against children: Intervention of nurses from the Family health strategy].13 Qualitative study Level VI 4 Ação interdisciplinar do enfermeiro à criança com suspeita de abuso sexual [Interdisciplinary action of nurses to children with suspected sexual abuse].8 Qualitative study Level VI 5 The nurse in sexual abuse child suspicion attention: a phenomenology approach.14 Qualitative study Level VI 6 Enfrentando os maus-tratos infantis nas Unidades de Saúde da Família: atuação dos enfermeiros [Facing the children abuse at Family Health Units: the performance of nurses].2 Qualitative study Level VI 7 Cuidado de enfermagem à criança vítima de violência sexual atendida em unidade de emergência hospitalar [Nursing care for sexually abused children in hospital emergency units].15 Qualitative study Level VI 8 Significado do cuidado às crianças vítimas de violência na ótica dos profissionais de saúde [The meaning of care for child victims of violence from the perspective of health professionals].16 Qualitative study Level VI 9 Crianças e adolescentes abrigados vítimas de violência: dilemas e perspectivas da enfermagem [Children and teenagers living in orphanages victims of violence: dilemmas and nursing perspectives].17 Qualitative study Level VI J. res.: fundam. care. online 2020 jan/dez 12: 115-123 117 ISSN 2175-5361 Silva MS, Milbrath VM, Santos BA et al. DOI: 10.9789/2175-5361.rpcfo.v12.7102 Nursing care for child/adolescent... Research Type of study Evidence level.12 Qualitative study Level VI 11 Abordagem dos profissionais de saúde em instituições hospitalares a crianças e adolescentes vítimas de violência [Approach of health professionals in hospitals to children and adolescents victims of violence].19 Quantitative study Level IV 12 Violência contra crianças e adolescentes: estratégias de cuidado adotadas por profissionais de saúde [Violence against children and adolescents: care strategies adopted by health professionals].20 Quantitative study Level IV 13 Atuação profissional da atenção básica de saúde face à identificação e notificação da violência infanto-juvenil [Professional performances of primary care health in the face of identification and notification of children and adolescents violence].21 Quantitative study Level IV 14 Concepções de profissionais de saúde sobre a violência intrafamiliar [Conception held by health professionals on violence against children and adolescents within the family].22 Qualitative study Level VI Quantitative study Level IV 16 Atenção a crianças e adolescentes vítimas de violência intrafamiliar por enfermeiros em serviços de pronto-atendimento [Attention to child and teenagers victims of intrafamiliar violence for nurses in health services of ready-care].24 Qualitative study Level VI 17 Notificação de violência contra crianças e adolescentes: atuação de enfermeiros de unidades básicas [Reporting of violence against children and adolescents: action of nurses in basic health units].25 Qualitative study Level VI 18 Vivências de enfermeiros no cuidado de crianças vítimas de violência intrafamiliar: uma análise fenomenológica [Nurses’ experiences caring for child victims of domestic violence: a phenomenological analysis].26 Qualitative study Level VI 19 O cuidado de enfermeiras à criança e ao adolescente vítima de violência doméstica: uma pesquisa qualitativa [Care provided by nurses to children and adolescents victims of domestic violence: a qualitative research].27 Qualitative study Level VI 10 A notificação da violência intrafamiliar contra crianças e adolescentes na percepção dos profissionais de saúde [The notification of domestic violence against children and adolescents in the perception of health professionals].18 15 Condutas adotadas pelos profissionais de saúde com crianças hospitalizadas vítimas de violência [Conducts adopted by health professionals on hospitalized children victim of violence].23 Table 2 - Characterization of the studies. Research 1 Sample 15 nurses Language Country Year Portuguese Brazil 2013 2 Eight nurses Portuguese Brazil 2013 3 14 nurses Portuguese Brazil 2012 4 11 nurses English Brazil 2014 5 11 nurses Portuguese Brazil 2009 6 Eight nurses Portuguese Brazil 2013 7 Four nurses, six technicians and one nursing assistant Portuguese Brazil 2010 8 Five nurses, five nursing assistants, two social workers and two doctors Portuguese Brazil 2013 9 Seven nurses Portuguese Brazil 2014 10 Four nurses, four nursing technicians, one social worker and one psychologist Portuguese Brazil 2009 11 34 health professionals including doctors, nurses and nursing technicians Portuguese Brazil 2010 12 Ten nurses, twenty nursing technicians and four doctors Portuguese Brazil 2010 13 582 health professionals Portuguese Brazil 2011 14 24 community health workers, two social workers, one dental assistant, one nursing assistant, two dentists, three nurses and two doctors Portuguese Brazil 2008 15 Seven social workers, 150 nursing assistants and technicians, 35 nurses, 38 doctors and five psychologists Portuguese Brazil 2008 16 13 nurses Portuguese Brazil 2009 17 Six nurses Portuguese Brazil 2013 18 15 nurses Portuguese Brazil 2013 19 11 nurses Portuguese Brazil 2008 J. res.: fundam. care. online 2020 jan/dez 12: 115-123 118 ISSN 2175-5361 Silva MS, Milbrath VM, Santos BA et al. The discussion of the results was divided into topics for better understanding, which are: unpreparedness of professionals regarding the child violence cases; feelings of the professionals involved in caring for the child/ adolescent victim of violence; notification, protocols and routines in the care of children/adolescents victims of violence; strategies for assistance to children/adolescents victims of violence. Unpreparedness of professionals regarding the child violence cases Among the studies, it was observed that some nursing professionals do not consider as their attribution the identification and approach of cases of child violence, so when confronted with any case they try to pass it on to other professionals such as social workers and psychologists.7,23 Nonetheless, other studies point out that nurses are responsible for addressing these cases, as indicated by the professionals themselves, who understand nursing consultation as an important instrument concerning the care of these children/adolescents.4,13 It is believed that nurses play an important role in detecting situations of child and youth violence, as well as in caring for victims and families. Considering the role of nurses in care, some professionals consider that, in most cases, their role in the management of primary care units addresses the general problems of the community in which they operate, preventing them from addressing issues related to child maltreatment. The underestimation and invisibility of violence make professional performance difficult, as the focus still remains on physical issues, so violence is seen as a minor problem facing the most frequent pathologies. The fact that violence is a matter of poor visibility within the communities, so resulting in the lack of perception of the problem by the professional, which makes it impossible to act on the theme.2 It is understood that violence is a health problem that significantly impacts the life of the victim and their family. Thus, it should be considered a priority when it comes to the care of children and adolescents. Although it often does not manifest clinical symptoms, it causes serious psychological consequences on human development. Therefore, it should not be underestimated nor compared to clinical pathologies, since they are different situations, and both need a careful and different look.2 The main difficulties pointed out in assisting these cases are related to the lack of qualification of nursing professionals, as there are no specific qualifications and it is not a subject of great approach during graduation. Thus, many professionals feel unprepared to deal with situations of child violence, creating a gap in important aspects in the identification of abuse, as well as in addressing victims and family members, so they understand the need to focus more on the topic during professional training practices.2,4 The fact that the formation of some categories of professionals is based exclusively on the physical issues of violence makes the actual diagnosis of the cases difficult.21 J. res.: fundam. care. online 2020 jan/dez 12: 115-123 DOI: 10.9789/2175-5361.rpcfo.v12.7102 Nursing care for child/adolescent... Considering this background, it is essential to carry out continuing education actions aimed at professional qualification, judging that professionals must be trained to deal with situations of violence, given that the inadequate handling of cases can have serious consequences for the children/adolescents, as well as for their families. This often ends up being forgotten by health professionals, however, it also needs care, as violence directly affects the family cycle and promotes disorganization, so professionals must be able to promote comprehensive and humanized care to all involved in this process. Part of the unpreparedness of professionals is that health care is based on a biomedical model that centralizes assistance to anatomical and physiological issues, leaving aside issues that are not exclusively understood by this view, and the focus of the investigation is part of evident signs of Physical aggression.7,19 Thus, professionals do not consider themselves capable of dealing with cases of abuse, a fact that hinders the identification of child violence, as well as the prevention of new cases.7 The literature indicates that over the years the violence has been treated in the health area, focusing only on the obvious injuries of aggression, directing its attention to the cases of greater physical severity, thus the health actions become incomplete, because if understands that violence does not always result in visible marks, but also mental and social.24 Sometimes there is an attempt to medicalize the phenomenon due to the difficulty of professionals in dealing with social issues.4 From this perspective, the importance of professionals pay attention to subjectivity, visualizing signs that are not evidenced physically, such as withdrawn behaviors of the child and contradictions between the stories told by the family and the victim.19 Another point found in the data analysis was that many professionals do not understand negligence and psychological violence as forms of abuse. A study of 13 nurses working in emergency units in Paraná State showed that they described aspects that include negligence, but did not mention it as a form of violence.24 In addition, another study, conducted with six nurses who work in primary health care units in Southern Brazil, also evidenced this fact, as the subjects reported to only notify cases of physical and sexual violence.25 Moreover, the disarticulation of the multi-professional team also highlights the unpreparedness of professionals vis-à-vis the violence against children/adolescents, as the professional often finds themselves alone in the face of a situation that needs the opinion of a multi-professional team. This fact does not contribute positively to the confrontation of violence, so the professional attitude towards these situations demands responsibility and an articulated action with all team members.18 It is emphasized the importance of addressing the theme of child violence during undergraduate nursing, as well as educational training for professionals working in the services and the general population due to the relevance and complexity of the theme, thus ensuring quality care and a decrease in the number of cases. 119 ISSN 2175-5361 Silva MS, Milbrath VM, Santos BA et al. Feelings of the professionals involved in caring for the child/adolescent victim of violence Concerning the impact that the approach to cases of child violence has on the nursing professionals involved, we highlight the various feelings that came about during the process of caring for the victims. These refer to both victims and aggressors. One of the main obstacles pointed out by health professionals refers to contact with cases, which refers to feelings of judgment, anguish and anger. Thus, one of the difficulties encountered by professionals is the ability to undress prejudices and judgments, because when faced with these cases do not understand how a person may be able to commit abuse against a child in their family, or how the child’s mother can defend the abuser. The authors identified feelings of pain and suffering on the part of the professionals regarding the child/adolescent who suffers the violence, and also anger towards the aggressors, especially when dealing with the victim’s family members.15 Judgment against the family is frequent among the professionals, because they consider that the family environment should be a protected place for the child and when this concept is broken, it causes anger and indignation.22 The most judged family member is the child’s mother, as it is considered that she should protect the child and not allow anything bad to happen to her/him. Then, when the mother omits or ignores the aggression suffered by the child, she becomes the main culprit of the situation.22,26 Thus, professionals feel the need to protect the victim by removing them from the violent environment and seeking the appropriate means so that they do not return to such a situation.26 From this perspective, it is important that nurses have the ability to set aside their judgments and try to intervene with the victims and their families to identify the causes and the type of abuse suffered, having empathy and knowing how to listen to the child/adolescent, because they show a lot through gestures, drawings, and speeches, a fact that facilitates the approach.3 The child might present subjective manifestations, even in childhood, that he/she is suffering abuse as learning difficulties, in addition to manifestations in adulthood, such as weak bonds and aggressiveness.4 Fear arises as a recurring feeling in the professionals involved in care, judging by their exposure to risky situations when the aggressor is a member of the child/adolescent’s family. However, many professionals are not silent about cases of violence and face obstacles to helping victims at risk.7,18 Despite the importance of maintaining confidentiality by the authorities concerning the notification or denunciation cases of violence, insecurity is also cited in several studies. Professionals often do not effectively comply with assistance, especially about notifications, since they do not have support for it, being exposed to repression by aggressors.2,13 Part of the fear and insecurity reported by professionals is due to the lack of secrecy of the Guardianship Council, which constantly exposes the complainants to the family. Therefore, professionals do not feel safe to notify the cases and end up omitting information necessary for family management, J. res.: fundam. care. online 2020 jan/dez 12: 115-123 DOI: 10.9789/2175-5361.rpcfo.v12.7102 Nursing care for child/adolescent... due to the fear of suffering repression and lack of protection from the competent authorities.25 A study conducted with professionals from a pediatric emergency department pointed out as the main limitation to the care of the child/adolescent victim of violence to the barriers imposed by the social and family reality of the country, as often the child is assisted at the service and returned to the environment, where their aggressor may be, and thus the cycle of violence will be perpetuated. This fact makes professionals feel helpless about the situation, and there must be a state and society accountability that guarantees the rights of children and adolescents.16 This mixed feeling results in an emotional overload of professionals involved in assisting the child/adolescent victim of violence and many report the difficulty of handling their feelings, a fact that may reflect the way they will approach the victim and family.16,26 It is also emphasized the need for a look focused on professionals who work in cases of violence, because of the intense emotional burden to which they are submitted, in addition to their exposure and lack of protection in cases of denunciation.4,17 Finally, there is a multiplicity of feelings involved in the care process for victims of violence. Therefore, professionals need to be emotionally organized to face difficult situations and to strip themselves of judgments and prejudices to ensure dignified and humane assistance. Besides, it is important for professionals to be sensitized and to be responsible for the care of the victim and their family so that the cycle of violence can be interrupted and the quality of life of those involved can be guaranteed. Notification, protocols and routines in the care of children/adolescents victims of violence Notification of child violence cases is among the duties of nurses, as of any health professional who receives reports of cases, but some professionals relate that there are many bureaucratic barriers that make reporting difficult, as the system does not work as it should, and it is necessary sometimes professionals use inappropriate means, such as help from someone known to work within the legal sectors.7,21 Another problem related to notifications is the fear on the part of professionals due to the aggressive history of family members of child/adolescents who are victims of abuse. Many nurses report that they do not feel safe to report because they fear to suffer some kind of repression by the child’s father or stepfather.2,25 About the notification, professionals are unaware of what should be notified in cases of violence, considering that they perform notification when there are obvious signs of aggression, disregarding aspects of psychological violence and neglect, reinforcing the focus on the biomedical model.25 There are worrying factors related to underreporting of violence, many professionals omit information and end up leaving the case so as not to get involved in the bureaucratic barriers they need to address, in addition to the lack of legal support to ensure their safety.7 In some studies, the compulsory notification form is not even cited as a practice adopted within 120 ISSN 2175-5361 Silva MS, Milbrath VM, Santos BA et al. the services.20 The professionals report that the notification occurs, but they are not doing it, showing that there is a recurring transfer of responsibilities in health services that reinforces the lack of knowledge about their attributions to cases of violence.21 Another factor pointed out by the professionals is the intersectoral disarticulation, judging that the professional within their attributions notifies and forwards the case to the organs responsible for the protection of the child and adolescent, but the case is not solved or not referred to the appropriate services, evidencing the disarticulation of the health service network.7,13 Professional frustration has also appeared frequently, given the recurring impunity in the country, many acknowledge the importance of filing the notification, but report feeling frustrated when the aggressor does not respond judicially for their actions.18,25 Impunity also appears as a complicating factor, considering that it is still such a fact present in the Brazilian system and that results in the victim being kept in a violent environment, without defense and protection. Therefore, the effective action of the competent authorities in the determination of protective measures for the victims, as well as the proper referral of the aggressors, interrupting the cycle of violence, is indispensable.2,16 Faced with impunity, professionals feel powerless regarding the integral care of the child/adolescent victim of violence, considering that they often carry out the notification process, but there are no positive results for the victim’s well-being, so they return to the violent environment without the aggressor being penalized.7 In most of the studies analyzed, the lack of a care protocol emerged as an impasse for the care of the victims, since from the absence of protocols, attention starts from the personal basis of each professional, a fact that may interfere with the paths that must be followed during the process.7,24 Thus, it is necessary to have protocols that support the professional performance and direct the cases to the appropriate referrals, judging that if the institution establishes a specific protocol for care, the professional feel safe and supported to take the necessary measures in cases of violence.18,24 Thus, the relevance of reporting cases of violence is highlighted, but studies show the unpreparedness of professionals in regard to the situation, thus emphasizing the importance of professional training to ensure the effectiveness of notifications. Also, the need for legal support that ensures the physical and psychological integrity of the professionals, preventing them from being exposed and suffering reprisals from the aggressors, as well as ensuring the effective referral of victims and aggressors is emphasized. Strategies for assistance to children/ adolescents victims of violence Given the difficulty of professionals in handling cases of violence, it is essential to constantly work with continuing education and training of all those involved in health care.2,19 Studies address the need for training of Community Health Workers (CHWs) as a fundamental tool, considering that J. res.: fundam. care. online 2020 jan/dez 12: 115-123 DOI: 10.9789/2175-5361.rpcfo.v12.7102 Nursing care for child/adolescent... these professionals are who have the greatest connection with the community, facilitating the process of early intervention for children/adolescents who are at risk of violence through home visits.2 Nurses consider that child violence should be tackled using educational activities with the community, such as health education activities in day care centers, schools, churches, waiting rooms, groups within the Basic Health Unit, and even in individual consultations, aiming at individuals’ access to the information needed to address the problem. Besides, they consider that the theme should be more addressed in the media facilitating access to information.7,13 Thus, the concern of professionals with health promotion and prevention was highlighted, considering the early detection of violence and the prevention of new cases.25 Nevertheless, despite the professionals’ knowledge about the importance of educational actions, many observe flaws in their effectiveness within primary care services, given that they do not perform activities with the community with the necessary focus, as they report that management duties make it impossible for them to have sufficient time to carry out educational activities.2 Some studies analyzed evidenced nursing consultation as an important tool in identifying and addressing cases of violence,4,21 judging that it favors closer ties with the child/adolescent and family, allowing greater focus on the pertinent issues regarding case intervention. Therefore, it is necessary to provide humanized care to victims as well as families, considering that the family is of paramount importance throughout the process and needs to be observed and cared for.14,5,17 A study conducted with professionals working in primary care showed that nurses are among the professionals who most identify cases of violence through nursing consultation, a fact that makes consultation an indispensable tool in the identification and intervention of cases.21 Another study showed that the nurse should be aware of the different signs and symptoms presented by the victims in order to provide adequate assistance and guarantee their quality of life.26 Thus, we emphasize the importance of active listening and observation to detect possible signs of any type of violence, in addition to nursing history, anamnesis and physical examination, in order to recognize physical and/ or psychological injuries resulting from this.14,24 It is noteworthy that clinical support is essential in addressing children/adolescents victims of violence, but psychological support to victims and their families cannot be postponed, given that most studies have shown that professionals are aware of the obvious signs of physical aggression and carelessness on the psychological side. Due to the serious consequences that violence can have on the lives of victims, psychological and therapeutic support is essential to ensure the mental strengthening of these children/adolescents and their reintegration into the social environment to improve their quality of life.24 As an important strategy, the notification of cases to the protective organs, aiming to remove the victim from the 121 ISSN 2175-5361 Silva MS, Milbrath VM, Santos BA et al. violent environment and ensure their quality of life, in addition to proper judicial referral to the aggressor.18,20,26 An effective strategy in addressing abused children/ adolescents who come to residential shelters is the use of playfulness, as many of them are unaware of the meaning of play, which is an important way of preserving childhood. Thus, the professionals understand that the child/adolescent who goes through this type of trauma cannot be cared for through strict and closed norms, but from a playful perspective of care, considering the importance of this for their recovery.17 It is important to highlight the role of nurses as fundamental professionals in the approach of these children/ adolescents, judging that they have direct contact with them and their families, so they need to exercise care based on bonding, welcoming and empathy, effectively providing care and ensuring that victims, as well as their relatives, feel safe and willing to express themselves.20 It is also noteworthy that nurses understand violence as a reflection of the social conditions to which families are exposed. Thus, they realize the importance of considering the social context and working on issues that are often understood, ensuring the quality of life of children/adolescents and their families.22 Therefore, nursing professionals consider as an important tool in assisting children victims of violence, the interdisciplinary approach with multi-professional interaction for these cases that ensures clinical, psychological and social support, understanding that the child/adolescent and the family need humanized care and which requires the intervention of multidisciplinary teams to ensure the quality of care.7,8,14,19,27 Moreover, Intersectoriality is cited as an indispensable strategy, given that a service does not act alone in assisting these cases, thus needing a joint work of the entire support network in order to establish referrals to services that guarantee the protection and preservation of the rights and integrity of the child/adolescent, as well as the appropriate referral of their aggressors preventing the cycle of violence from being perpetuated.2,8 CONCLUSIONS Nursing professionals do not feel prepared to act/identify victims of violence, so when facing children and adolescents under this situation, they find themselves amid conflicts related to cultural, ethical and legal aspects, failing to provide effective assistance to the needs of children/teenagers and their families. Furthermore, in many cases, it focuses on the biological, without attending to the subjectivity of the victim. In this sense, there is a need to include this theme in the academic education of professionals, not only in the health sciences, but also in social and human sciences, with the aim of equipping them for their role in cases of violence, especially when it comes to children/adolescents and family, considering that in many cases violence occurs within the family nucleus. Attention must also be paid to multi-professional care with an interdisciplinary approach, with the formation of social and J. res.: fundam. care. online 2020 jan/dez 12: 115-123 DOI: 10.9789/2175-5361.rpcfo.v12.7102 Nursing care for child/adolescent... health care networks, interinstitutional and intersectoral, that provide care to the whole family, transcending the biological dimension of care, meeting the real needs of the victim, the family and the context in which violence occurs. There is a need to create service protocols that support the identification of the problem, aiming at proposing solutions and decision making. In this sense, it is necessary to make referrals and to elaborate intervention and violence control strategies, as well as to offer legal support to the professionals who act on the cases and make the notifications. This is all to prevent new cases of violence from happening or even continuing in a vicious circle of impunity and injustice against children and adolescents. It is suggested that the multi-professional team, especially nurses, work with permanent health education, in an attempt to prevent this violence from happening, especially in the territorial areas of greater vulnerability. Given this framework, it is necessary to assist victims as well as aggressors seeking integrality in the treatment of the issue and assistance to all involved. REFERENCES 1. Organização Mundial da Saúde. Relatório mundial sobre violência e saúde. 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O cuidado de enfermeiras à criança e ao adolescente vítima de violência doméstica: uma pesquisa qualitativa. Online Brazilian Journal of Nursing. 2008; 7(1). Received in: 12/12/2017 Required revisions: Did not have Approved in: 16/04/2018 Published in: 10/01/2020 Corresponding author Manoella Souza da Silva Address: R. Vitor Francisco Ney, 785, Três Vendas Pelotas/RS, Brazil Zip code: 96.065-774 E-mail address: [email protected] Telephone number: +55 (53) 99153-0447 Disclosure: The authors claim to have no conflict of interest. J. res.: fundam. care. online 2020 jan/dez 12: 115-123 123