Increasingly, public attention is focused on the issues related to violence in the United States. Escalating incidences of violence against women and children is of special concern. For example, 42 offenses of forcible rape per 100,000 population were reported to police in 1991 (Federal Bureau of Investigation, 1992); the actual incidence of violence against women is probably much higher as only 54% of rapes were reported (Bureau of Justice Statistics, 1992). Because victimization against women occurs inside the home as well as outside the home, women have Little refuge from violent behavior (Koss, 1993). The American Nurses Association issued a position statement on physical violence against women in 1991 (ANA, 1991). The American Medical Association considers that violence against women has reached epidemic proportions, and recently recommended that all women be routinely screened for domestic abuse (Council on Scientific Affairs, 1992).
Violence against children is reflected in the alarming statistic that homicide is the leading course of death of infants under 2 years of age, excluding death within the first 6 weeks after birth (U.S. Department of Health and Human Services, 1989). The extent of abuse against elders is reflected by the American Academy of Nursing report that abuse of 700,000 to 1.2 million elders occurs annually (AAN Expert Panel on Violence, 1993). Although the elderly are less likely to be crime victims, they are more likely than those who are younger to be harmed by strangers, to sustain serious injuries, and to be victimized in or near their homes (Bachman, 1992).
Violence, one of 22 priority areas of Healthy People 2000, is considered a serious health problem in the United States (U.S. Department of Health and Human Services, 1990). Major concerns of the health and criminal justice systems are the immediate and long-term effects of violence on its victims and survivors. In 1989, Brendtro and Bowker reported that despite the involvement of health care workers in the care and treatment of victims of violence, they have been viewed as the least helpful of all professional sources. Fishwick (1993) described the response of health care professionals to battered women living in rural areas as unpredictable.
Recently, however, nurses, because they are the largest single group of health care professionals and because of their presence in virtually all health care settings, are in an ideal position to be in the forefront of the nation's fight against violence. Nurses can address the problem of violence from all perspectives of the health continuum: prevention, diagnosis, treatment and rehabilitation. Several authors have indicated the vital role nurses can play in primary prevention of abuse, helping women leave abusive relationships, addressing violence in Native American communities, providing leadership in changing public policy, teaching about abuse, intervening for abused women on obstetrical units, and screening for abuse in the clinical setting (Bohn, 1993; Bullock, 1993; Campbell, 1993; Purniss, 1993; King, 1993; Eoss & Hoff 1994; Ryan & King 1993; Ulrich, 1993). Whether nurses are adequately prepared to assume their potential professional role against violence and provide the needed support for victims and their families is not clear. Certainly, the educational preparation of nurses is a key factor in their effective participation in health promotion strategies for women, children and elders.
Characteristics of the society in which the nursing student is prepared to practice must be a consideration for inclusion of content in basic nursing education programs. Nurse educators have the opportunity to prepare nursing students for their assessment and treatment roles in the care of victims and survivors of violent episodes, and encourage their advocacy role in supporting public education and activism. Nurse educators are also accountable for assuring the relevancy of curriculum to the school, the profession and the society of which it is a part.
Examination of the relevancy of nursing curricula is most clearly addressed through collection, analysis, and interpretation of appropriate data. Yet research related to the adequacy of preparation of nursing students to provide appropriate care to victims of violence has not been systematically investigated. A first step is to explore how and to what extent nursing students are currently prepared for their prevention and treatment roles: using these data, nurse educators can address the research issues related to adequacy of preparation, specific content, instructional methods and educational outcomes.
A review of the nursing literature revealed little information about the inclusion of violence-related issues in nursing curricula in the United States. The questions become: what violence-related content is currently included in nursing curriculum, where is it taught, and who teaches it?
The purposes of this study were to identify the extent, placement and faculty responsible for content on abuse and violence against women, children and elders in nursing curriculum in accredited nursing programs in the United States and to describe the perceived needs of faculty for curriculum development activities related to violence.
The framework for this study is grounded within an ecological model from a health promotion perspective. Violence within society has been documented as a public health concern needing attention from health care professionals (U.S. Department of Health and Human Services, 1990). To decrease the incidence of violence and promote health of individuals, families, communities, and the society at large, solutions to this health problem must be directed at multiple levels within society. From the perspective of a social institution whose primary responsibility is the education of its students through a formalized curriculum and program of study, nursing education can have an important role to play in preventing violence and promoting health and safety of vulnerable persons.
The ecological model for health promotion described by McLeroy, Bibeau, Steckler and Glanz (1988) proposes that behavior ie influenced by five factors:
1. Intrapersonal factors, which consist of the individual's unique characteristics such as knowledge, attitudes, beliefs and personality traits
2. Interpersonal processes, which recognize social networks and support systems as major influences on behavior
3. Institutional factors, which focus on social institutions, such as educational systems, with formal rules and regulations for operations
4. Community factors, which involve the relationships between institutions, organizations and informal networks
5. Public policy, which includes local, state, and national laws and policies
Each of these factors may incorporate specific health promotion strategies focused on a specific phenomenon of concern, such as violence. Nursing education, through its formal curriculum, can serve a role in preparing future generations of nurses to intervene at all five levels: individual, social, institutional, community, and state/national. Curricular content related to each of the five levels could guide the integration of health promotion techniques designed to address the issue of violence. This ecological model provided the focus for the exploratory national study that was undertaken to examine nursing content currently presented regarding violence against women, children and elders, as well as a method to identify faculty needs for curriculum development activities.
A review of the published literature revealed few publications that described inclusion of content about violence against women, children or elders in health care curricula. This finding is in contrast to the reports of the 1986 Surgeon General's Workshop on Violence and Public Health and the Attorney General's 1984 Task Force on Family Violence in which both groups recommended that curricula of medical schools and other relevant professional schools include education about domestic violence (U.S. Department of Health and Human Services, 1989). In addition to a review of the curriculum, articles, selected comments from other publications related to violence in nursing research and nursing education are included in the literature review.
The New Jersey Medical School Domestic Violence Prevention Project surveyed all accredited medical schools in the United States and Canada (n=143) during the 1987-1988 academic year to determine curriculum content about adult domestic violence (U.S. Department of Health and Human Services, 1989). Eighty-one percent (ra=116) of the schools responded and provided data about instruction that pertained to various types of adult domestic violence. The survey identified adult domestic violence as physical, emotional, sexual, spouse, and elder abuse, battered women, and dating violence. Of the 116 schools that responded to the survey, 61 (53%) reported that their students received no instruction about adult domestic violence. Forty-nine (42%) respondents indicated that their students received instruction as part of at least one course. Six schools (5%) reported that, although their students received no required course or instruction, the students could choose to receive instruction about adult domestic violence as part of an elective course. For schools that did require instruction, the mean number of sessions offered was 1.5, and the mean number of hours per session was 1.9, with a range of hours from 0.5 to 6.0. Departments of psychiatry or other behavioral sciences taught 63% of the sessions on adult domestic violence. Other specialty areas in which instruction was provided included family practice, geriatrics, internal medicine, community/environmental health, obstetrics and gynecology, pathology and surgery. Because the medical schools were classified as offering instruction even if the instruction was confined to only one area of abuse, the finding that 58% of schools did not require instruction in adult domestic violence may be a conservative estimate (U.S. Department of Health and Human Services, 1989).
In a regional survey of 1,571 practicing clinicians in six disciplines including nursing, findings indicated that more than one-third of the subjects reported no educational content on spouse, child, or elder abuse in their professional programs (Tilden, Schmidt, Lunandri, Chiodo, Garland, & Loveless, 1994). The investigators concluded that a need exists to expand curriculum in family violence.
Kerr (1992) described the incorporation of content about violence against women into an undergraduate nursing curriculum at Capital University. She identified ten curriculum objectives and described two courses, Human Growth and Development and Psychosocial Nursing, in which violence against women was primarily addressed. Kerr indicated that clinical sites included an acute adult inpatient psychiatric setting; outpatient settings such as a safe house for abused women and their children, a safe house and crisis intervention center for runaway teens; and a family-centered inpatient and outpatient chemical abuse treatment program. Teaching methods included selected reading materials and videotapes, clinical discussion conferences, role playing, journal entries, and a visit to a student selected community agency. Evaluation of curriculum goals, impact of the classroom and clinical experiences on student learning and alternative curriculum plans were described. Kenstated that it is essential for nursing students to learn about abuse and appropriate intervention strategies because the nurse is often the first health care member to recognize abuse and care for the abuse victims.
Hoff and Ross (1995) reported the results of a survey of nursing schools in Ontario, Canada whose purposes were to determine the curricular approaches to content on abuse and violence and to identify curriculum development needs of faculty. They identified several strategic issues which they considered central to the curriculum development process and described a series of six workshops held throughout Ontario to assist nurse educators with the task of systematically addressing violence in nursing curricula. The workshop participants included faculty, clinical preceptors and community-based experts in victim/survivor care. The authors indicated that the workshops are an initial step in addressing curriculum development related to inclusion of violence content in nursing curricula.
Ross and Hoff (1994) described the project of The University of Ottawa School of Nursing to develop a curriculum guide to assist nurses in academic and clinical settings to systematically include content related to violence and victimization in their teaching. The guide provides a comprehensive approach to the knowledge, attitudes and skills needed by nurses and other health providers across several categories of abuse. Moreover, the guide incorporates information about risk factors, demographic factors, links to caretaking, and systematic coverage of content in nursing curricula.
McBride (1992, p. 88) noted that violence against women has been a "relatively invisible curriculum topic" and urged that in the future it be viewed as a major area of study by nursing education programs. She advocated that violence against women be considered a major nursing research initiative in developing nursing's research agenda and urged nurses to assume leadership in pursuing research targeting treatment-related questions. An American Academy of Nursing working paper (AAN Expert Panel on Violence, 1993) indicated that nurses, nursing organizations and nursing research have made a difference in changing national policy on prevention of violence and abuse, and have provided leadership in making the health care system partners with the judicial system in dealing with violence. Because of the prevalence of the abuse of women and the health problems, suicide, and homicide that result, the need for basic nursing education and continuing education in all settings is recognized by the American Academy of Nurses.
Campbell (1992) emphasized the importance of promoting nursing leadership in a reformed health care system by involving nursing students in the effort to prevent violence to women and to be responsive to women as victims. She stated that students can learn about violence against women in any clinical setting in which there are women, but recommended carefully planning and guiding the clinical practice of nursing students. She suggested using the principles of the curriculum revolution, especially the students' ways of knowing, as a framework for student learning.
A descriptive survey design was used to collect information from schools of nursing related to curriculum content focused on violence against women, children and elders. A mailed questionnaire was sent to the dean or director of all baccalaureate and higher degree nursing programs accredited by the National League for Nursing (NLN).
The sample was all NLN-accredited baccalaureate and higher degree nursing programs; the list of NLNapproved schools was obtained from a 1993 list provided by the NLN. Deans or directors of nursing programs were asked in a cover letter to select a faculty member or members from their program to participate in the study by completing the questionnaire. The total number of nursing programs surveyed was 622.
Data Collection Instrument
A survey instrument, "Violence Against Women and Children: Curriculum Content in Schools of Nursing," developed by Dr. Lee Ann Hoff and Dr. Margaret Ross was used in this study. Permission was obtained from the authors for use of the questionnaire that they developed as part of a nursing curriculum research project in Ontario, Canada. Drs. Hoff and Ross investigated content related to violence against women and children in Ontario nursing programs and subsequently developed a curriculum guide for nurses (Hoff & Roes, 1993).
Survey items were reviewed for content validity by three experts in the field of violence. The pilot survey was initially sent to all Ontario schools of nursing (n=43). Ninety-three percent of the schools returned the pilot survey. The Hoff and Ross pilot survey was modified to clarify and enhance the questionnaire (personal communication). The initial Ontario project resulted in the development of a curriculum guide related to violence content in Schools of Nursing (Hoff & Ross, 1993, 1995).
The 35-item questionnaire is composed of three sections. The first eight demographic items are related to a description of the nursing program, including information about types of programs offered, and the number, employment statue, and educational preparation of faculty. The next 18 items focus on course content related to child abuse, woman abuse/battering, sexual assault/rape, elder abuse, and suicide/self-destructive behavior. The last nine items refer to curriculum development and include questions related to perceived adequacy of content, need for additional curriculum development activities, and status of current curriculum planning or revision. The last question is open-ended and seeks additional comments from the respondent about the contribution of nursing to prevention of violence against women and children.
Protection of Human Subjects
Approval for this study was obtained from the Northern Arizona University Institutional Review Board and was funded by a grant from Applied Research or Service Grants at Northern Arizona University. A cover letter accompanying the questionnaire explained the purpose of the study and assured the respondent that participation was voluntary. Completion and return of the instrument indicated voluntary consent to participate. As no names were used on the questionnaires, confidentiality of the responses was assured. Code numbers were used for data analysis purposes and only summary data are reported.
Questionnaires were mailed to 622 accredited nursing programs. Of the 622 mailed questionnaires, 306 (49%) were returned. Of those returned, 298 (48%) were analyzed. Eight of the returned questionnaires were not usable because respondents indicated the nursing programs were closed or closing and did not complete the questionnaire, or the questionnaire contained large amounts of missing data.
Table 1 presents demographic information that describes the type of nursing education program, total enrollment, and the number and preparation of faculty.
Of the 298 nursing programs, 229 offered RN to BSN completion options, 228 offered generic baccalaureate education, 122 offered master's programs, and 46 offered the associate degree. One diploma school responded. Ten percent of the programs enrolled under 100 students but 23% enrolled 400 or more students. More than half the schools reported enrollments of between 100 and 300 students.
Child Abuse. Nearly 40% of the programs reported two hours or less of content related to child abuse while 21% of the respondents said that their programs included more than four hours of child abuse content. Most of the content was included in courses related to nursing of children (57%), community health nursing (53%), and psychiatric/mental health nursing (44%). Faculty prepared in clinical areas of child health (61%), psychiatric/mental health (57%), and community health (52%) taught most of the child abuse content.
Description of Nursing Programs (n=298)
Course Content In Hours of Classroom Instruction
Woman Abuse/Battering. Fifty-nine percent of the programs reported two hours or less of content related to woman abuse/battering. Another 22% of programs reported either three or four hours devoted to this topic. The primary courses in which this content was covered were psychiatric/mental health nursing (52%) and community health nursing (46%). One-quarter of the programs reported that this content was in maternity nursing. Faculty prepared in psychiatric/mental health nursing (62%), community health nursing (47%) and maternity nursing (29%) were primarily responsible for presenting content on woman abuse/battering.
Sexual Assault/Rape. This content is covered in two hours or less in 58% of the 298 programs while 14% of the programs report three or four hours are devoted to classroom instruction. The primary courses in which this content is covered are psychiatric/mental health (57%) and community health nursing (31%). As expected, faculty prepared in psychiatric/mental health and community health nursing provide most of the content related to sexual assault and rape.
Elder Abuse. Two or fewer hours in 67% of the programs who responded are devoted to the topic of elder abuse. In 9% of the programs, the content is covered in reading only. The content is nearly evenly distributed among community health nursing (39%), psychiatric mental health (44%), and gerontological nursing (33%). Faculty responsible for teaching this content are prepared in psychiatric mental health (44%), community health (39%) and gerontological nursing (33%).
Content by Course Type
Course-Content by Clinical Preparation of Faculty
Suicide/Self-Destructive Behavior. In 52% of the programs, content is covered in two hours or less, while 30% of the programs cover the content in three or four hours. In 79% of the programs the content is presented in psychiatric/mental health nursing while 20% of the programs report content covered in community health nursing courses. As expected, 87% of the programs reported that faculty prepared in psychiatric/mental health teach the content on suicide and self-destructive behavior.
Related Content. Approximately 89% of the 298 respondents reported that their curricula included content on nonviolent conflict resolution, stress reduction, crisis theory and crisis intervention.
Clinical Practice Opportunities
When responding to the question about student clinical practice opportunities in the area of child and woman abuse, 78% of the programs reported that the experiences are coincidental with other planned experiences, such as prenatal clinics or care of hospitalized patients. One-third of the programs reported specifically planned learning experiences in a battered women's shelter, and another 30% reported opportunities for students to volunteer in shelters or rape crisis centers.
More than half (53%) of the respondents indicated that they believed their curriculum adequately addressed content related to violence against women and children while 12% were not sure. Thirty-five percent of the respondents reported that their curriculum does not adequately address violence against women and children. The major reason given for inadequate attention to this content was insufficient time, considering total curriculum requirements.
Sixty-eight percent of respondents indicated that they were interested in a curriculum development workshop to address these areas of curriculum content and suggested topics such as an update on knowledge and research related to child and woman abuse; refresher on skills such as victimization assessment and crisis intervention; curriculum development; and student practice opportunities. Nearly half of the respondents (44%) indicated that their programs were in the process of major curriculum revisions.
In general, findings show that most nursing programs surveyed do include content related to child and elder abuse, woman abuse/battering, sexual assault/rape, and suicide/self destructive behavior. From 40% to 60% of the respondents indicated that the specific areas of content were presented in two hours or less. Programs generally spent the most time on child abuse content with approximately 20% of the programs including more than four hours of child abuse content. The least amount of time was spent on elder abuse, with nearly 10% of the programs covering the content in readings only. Content related to woman abuse, battering, sexual assault and rape was presented in two hours or less by more than half of the responding schools. Similarly, in slightly more than half of the programs, content related to suicide and self destructive behavior was presented in two hours or less.
Some of these findings are strikingly similar to those found by Hoff and Ross (1995) in their survey of nursing schools in the province of Ontario. For example, they found that child abuse content commanded the most hours and that elder abuse had the least coverage and was the only topic covered by readings only. Both surveys found that content related to woman abuse/battering was presented most frequently in psychiatric and mental health courses by faculty prepared in psychiatric and mental health nursing. Hoff and Ross (1995) attribute this placement of content to the traditional perspective of the individual woman's psychopathology rather than an issue related to gender, power, and abuse.
Most topics received between two and four hours of classroom instruction, with topical content presented in several courses. In addition, clinical practice opportunities with abuse victims were primarily coincidental with other planned experiences. However, 53% of the U.S. educators who responded believed that content was adequately addressed but only 30% of Canadian educators were satisfied; 45% of Canadian educators believed that content was not adequately addressed compared to 35% of US educators. Twice as many Canadian educators were not sure whether the content was adequately covered. Canadian educators (90%) seemed somewhat more interested in curriculum development workshops or seminars than did US educators (67%). Nurse educators from both countries suggested many of the same topics for faculty development workshops. Comparative findings from the Ontario and United States surveys should be considered cautiously and in the context of wide differences in response rates: 48% from US schools and 93% from Ontario schools.
Given that 44% of 298 nursing programs indicated that they were undergoing curriculum revisions, this is an opportune time to pose questions to guide curriculum, discussions. Tanner (1993), relating a personal encounter with the reality of violence against women, urges nurse educators to take a close look at their programs. The content, its placement and extent is an issue for each faculty to discuss and decide. Obviously there is no "right content in the right place(s) in the right amount taught by the right people in the right way."
Certainly these findings must be interpreted with caution and in relationship to the study's limitations. Because fewer than half of the NLN-accredited schools responded to the survey, findings are based on less than half of the target population. There was no attempt to randomize or stratify the sample; therefore, it cannot be assumed that the schools who chose not to complete the survey have similar curricular content, focus, learning experiences, faculty preparation, or faculty development.
There are, however, a series of questions that each faculty must ask as it examines the relevancy of its curriculum to the society whose needs nursing meets. One question concerns the profession's responsibility to educationally prepare its students in ways that promote the health of women and children. Related questions are the traditional ones faculty ask about desired curricular outcomes, teaching strategies, learning opportunities, student competencies. Another series of questions focus on the students' own experiences with abusive relationships, their individual ways of knowing, and their own evolving professional consciousness. A third set of questions involves the appropriateness of an ecological framework as a way of systematically examining the problem of violence, the process of intervention, and the proposed approaches/solutions within nursing. Finally, questions related to what McBride (1992, p. 88) called the "relatively invisible curriculum topic of violence," The invisible curriculum questions address the issue: which curriculum? By not making violence against women visible, are we not giving messages that "covertly communicate priorities, relationships, and values" (Bevis & Watson, 1989, p. 75)?
The use to which these findings are put may enable nurse educators to find some of the answers to the problems of violence, abuse, and victimization of women and children. As nurse educators we must at least ask the questions.
- AAN Expert Panel on Violence. (1993). AAN working paper: Violence as a nursing priority: Policy implications. Nursing Outlook, 41, 83-92.
- American Nurses Association. (1991). Position statement on physical violence against women. Kansas City, MO: Author.
- Bachman, R. (1992). Elderly victims. Bureau of Justice Statistics Special Report. Office of Justice Programs: Bureau of Justice Statistics. Washington, DC: US Government Printing Office, 1-9.
- Bevis, E.O., & Watson, J. (1989). Tbward a caring curriculum: A new pedagogy for nursing. New York, NY: National League for Nursing.
- Bohn, D. (1993). Nursing care of Native American battered women. Clinical Issues, 4(3), 424-436.
- Brendtro, M-, 4 Bowker, H.L. (1989). Battered women: How can nurses help? Issues in Mental Health Nursing, 10, 169-180.
- Bullock, L.F.C. (1993). Nursing interventions for abused women on obstetrical unita. Clinical Issues, 4(3), 371-377.
- Bureau of Justice Statistics. (1992). Criminal victimization in the United States, 1991. Washington, D.C.: U.S. Department of Justice.
- Campbell, J.C. (1992). Ways of teaching, learning, and knowing about violence against women. Nursing & Health Care, 13, 464-470.
- Campbell, J.C. (1993). Woman abuse and public policy: Potential for nursing action. Clinical Issues, 4(3), 503-512.
- Council on Scientific Affaire. (1992). Violence against women: Relevance for medical practitioners. Journal of the American Medical Association, 257, 3184-3189.
- Federal Bureau of Investigation (1992). Uniform crime reports. Washington, D.C.: U.S. Department of Justice.
- Fishwick, N. (1993). Nursing care of the rural battered women. Clinical Issues, 4(3), 441-448.
- Furnias, K. (1993). Screening for abuse in the clinical setting. Clinical Issues, 4(3), 402-406.
- Hoff, LA., & Ross, M. (1993). Curriculum guide for nursing: Violence against women and children. Ottawa: University of Ottawa, Faculty of Health Sciences, School of Nursing.
- Hoff, L.A., & Robs, M. (1995). Violence content in nursing curricula: Strategic issues and implementation. Journal of Advanced Nursing, 21, 1-6.
- Kerr, R. (1992). Incorporating violence against women content into the undergraduate curriculum. In CM. Sampselle (Ed.), Violence against women: Nursing research, education, and practice issues (pp. 117-130). New York, NY: Hemisphere.
- King, M. C. (1993). Changing women's lives: The primary prevention of violence against women. Clinical Issues, 4(3), 449-457.
- Koss, M. R (1993). Rape: Social impact, interventions, and public policy responses. American Psychologist, 48, 1062-1069.
- McBride, A. (1992). Violence against women: Overreaching themes and implications for nursing's research agenda. In CM. Sampselle (Ed.), Violence against women: Nursing research, education, and practice issues (pp. 83-89). New York, NY: Hemisphere.
- McLeroy, K., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15, 351-377.
- Ross, M-, & Hoff, L.A. (1994), Teaching nurses about abuse. The Canadian Nurse, 90, 33-36.
- Ryan, J., & King, C. (1993). Woman abuse: Educational strategies to change nursing practice. Clinical Issues, 4(3), 483-492.
- Tanner, C. (1993). Nursing education and violence against women (editorial). Journal of Nursing Education, 32, 339-340.
- Tilden, V., Schmidt, T., Lunandri, B., Chiodo, G., Garland, M., & Loveless, P. (1994). Factors that influence clinicians' assessment and management of family violence. American Journal of Public Health, 84, 628, 633.
- Ulrich, Y.C. (1993). What helped moat in learning spouse abuse: Implications for interventions. Clinical Issues, 4(3), 385390.
- United States Department of Health and Human Services. (1989). Education about adult domestic violence in U.S. and Canadian Medical Schools, 1987-1988. Morbidity and Mortality Weekly Report, 38, 17-19.
- United States Department of Health and Human Services (1990). Healthy people 2000: National health promotion and disease prevention objectives. DHHS publication number PHS 9150212. Washington, DC: US. Government Printing Office.
Description of Nursing Programs (n=298)
Course Content In Hours of Classroom Instruction
Content by Course Type
Course-Content by Clinical Preparation of Faculty