Abuse of women by their intimate partners has been identified as a priority women's health issue by government agencies, women's organizations, and health and social welfare organizations. Given the estimated prevalence of this problem and the physical and psychological health consequences, it is essential that health providers learn to respond effectively to women who have been abused. According to the Canadian Nurses Association (1992), nurses have a responsibility to identify, assess, and intervene in situations of abuse; yet, the literature suggests that often nurses do not adequately address the needs of women who are victims of abuse. This weakness is attributable, in part, to insufficient preparation in nursing programe.
Bishop and Patterson (1992) hypothesize that "culturally embedded sexist attitudee...can alter diagnosis, treatment offered and interpretation of women's responses to treatment* (p. 464) by health care professionals. Lack of recognition of abuse and lack of appropriate response when abuse is suspected or confirmed have been found to be widespread within the health care system (Ferris & Tudiver, 1992; McLeer & Anwar, 1989; Morrison, 1988; Tilden et al., 1994; Tilden & Shepherd, 1987). Women who have been abused perceive health care professionals to be lacking in their effectiveness to help, as compared to other formal or informal sources of help (Brendtro & Bowker, 1989; Dobash & Dobash, 1988; Drake, 1982). Although health care professionals reportedly are effective in treating the physical injuries resulting from abuse, they are less effective in treating the underlying causes of abuse and in dealing with the issue of safety (McLeer & Anwar, 1987; Randall, 1990; Warsbaw, 1989). Moreover, women who seek help from health care professionals often feel they are treated in an insensitive and judgmental manner (Dobash & Dobash, 1988; Kurtz, 1987) and are subject to labeling (Kurtz & Stark, 1988).
Inadequate preparation in professional education programs is suggested as a reason for the inadequacy of health care professionals in addressing the needs of women who have been abused (Rose & Saunders, 1986; Ross & Hoff, 1994). Increasing curriculum content is frequently cited as a strategy for improving nurses' ability to work with survivors of woman abuse (Campbell, 1992, 1993; Cohen & Wardell, 1992; Humphreys & Fulmer, 1993; Kerr, 1992; Urbanic, Campbell, & Humphries, 1993). However, studies reveal the general lack of content on woman abuse in basic nursing education programs (King & Ryan, 1989; Tilden et al., 1994). In Ontario, a 1992 survey of schools of nursing reported that the topic of woman abuse was addressed in classrooms an average of 2 to 4 hours, exposure in clinical courses was mostly incidental, and only Il schools reported including planned experiences in the curriculum (Hoff & Ross, 1995). Furthermore, the literature suggests that many types of educational initiatives guide nurses to practice a medical model of helping that does not empower women and is not holistic in its approach to women's experiences of abuse (King, 1988; Warshaw, 1989).
The inclusion of woman abuse content in professional nursing education has been shown to improve nurses' responses to woman abuse survivors. Educational exposure to the topic of woman abuse has been found to be directly correlated with the belief that survivors should be helped (Rose & Saunders, 1986) and with the likelihood of screening for child or elder abuse, but not spousal abuse (Tilden et al., 1994). Mandt (1993) showed that nursing studente who completed a mandatory course dealing with violence were more aware of abuse as a possible diagnosis, considered the effects of abuse beyond the physical injuries, and were lees judgmental of survivors. It is evident that including content on woman abuse in nursing curricula is a priority for improving nurses' ability to address the needs of women who have been abused.
Woman Abuse Curriculum Project
The Women's Health Office of McMaster University Faculty of Health Sciences initiated a Women Abuse Curriculum Project to sensitize students in health sciences and social work to the issue of woman abuse and to enhance their ability to respond appropriately and effectively. For this project, woman abuse was defined broadly as follows:
Woman abuse ia a woman's experience of intimidation, either by threat or use of force, against her, her children, or her property. Abuse does not necessarily involve physical contact with the woman; any act of intimidation can achieve the same result. The intent of any abuse U to control the woman's behaviour by the inducement of fear. Underlying all abuse is a power imbalance between the woman and the offender. (Women's Health Office, 1994, p. 3)
To provide baseline data and give direction for curriculum development, students' level of exposure and attitudes toward woman abuse were assessed. The McMaster University nursing curriculum includes core courses in anatomy and physiology, nursing concepts and theory, nursing practice, health sciences research, and current trends and issues. Although students are exposed to a variety of education strategies, the emphasis on selfdirected learning allows flexibility and diversity throughout the program.
Sample and Procedure. A convenience sample of students was obtained from each level and stream of the baccalaureate nursing program. Students at McMaster University enter one of two streams of study: diploma-prepared nurses are enrolled in a 2-year program of study (post-diploma stream), whereas other applicants are required to complete a 4-year program (basic stream). Thus, the total student body is heterogeneous with regard to age, prior education, and life experiences. Questionnaire packages were distributed to the students at the conclusion of a tutorial session, and completed packages were collected and returned to the researchers by faculty tutors. Completion of the questionnaires was anonymous, with respondents being identified only by program stream, level, age, and gender.
Instrumenta. The Student Exposure to Woman Abuse Questionnaire (SEWAQ) was used to establish the nature and extent of exposure to the issue in professional programs. This 29-item scale was developed specifically for the project and addresses a range of concepts relevant to woman abuse. Students indicated whether they had learned about the items in theory courses, clinical courses, or both. The questionnaire was found to have an internal consistency of .96 with item-total correlations ranging from .32 to .78. Face and content validity were achieved by having experts from the community and the university review the items and provide feedback.
In addition, to determine students' exposure to woman abuse through experiences external to the nursing program, they were asked to identify the following as sources of personal knowledge about women abuse: articles, books, or pamphlets; television programs, films, or videos; lectures, conferences, or workshops; hospital inservice sessions or rounds; volunteer work; personal experience; work experience; elective course work; and other means.
The Inventory of Beliefs about Wife Beating (IBWB) (Saunders, Lynch, Grayson, & Linz, 1987) was used to measure student attitudes. Although this scale focuses only on attitudes toward a husband physically abusing his wife and not toward woman abuse as more broadly defined for the project, it has been tested previously and demonstrates adequate reliability and validity. The IBWB is a 31item questionnaire consisting of 5 subscales derived using factor analysis:
* Wife Beating is Justified.
* Wives Gain from Beatings.
* Help Should be Given.
* Offender Should be Punished.
* Offender is Responsible.
Respondents use a 7-point Likert-type scale ranging from "strongly agree" to "strongly disagree." The standardized alpha coefficients of the internal reliability of the scales range from .61 to .89. (Saunders et al., 1987).
A total of 150 nursing studente were surveyed. Respondents were relatively equally distributed across all levels of the program. Age distribution reflected the traditionally observed findings in the program with students in the basic stream generally being younger than those in the post-diploma stream. Because the vast majority (96.4%) of students were female, it was not meaningful to analyze data according to gender.
Respondents' scores on the SEWAQ ranged from 4 to 41 (maximum score = 58). Mean scores by program level were calculated and ranged from 7.44 in Level I* (SD = 7.67) to 19.73 in Level IV (SD = 8.85) for students in the basic stream, and 9.81 in Level HI (SD = 7.52) to 16.56 in Level IV (SD = 11.84) for students in the post-diploma stream. The differences in exposure between program streams were not statistically significant. When data from both streams were combined, statistically significant differences in total exposure scores were found between Levels II and III, and between Level IV and each of the preceding levels (F = 17.06; p = .00).
Student learning about woman abuse within nursing courses was reportedly limited. The total mean score of 11.53 (SD = 8.89) for nursing studente was the second lowest of the five student groups surveyed. Only physiotherapy students scored lower with a mean of 5.68 (SD = 3.79). Mean exposure scores for other student groups were as follows: occupational therapy 12.79 (SD = 7.19); medicine 17.13 (SD = 8.28); and social work 21.72 (SD = 12.36).
The content items most frequently identified by nursing students were psyetiological impact (42.6%), why women stay or leave (39.3%), community resources (38.0%), involvement of child protection agencies (36.7%), the relationship between power and violence (36.0%), and presenting problems (35.3%). In contrast, nursing students reported little exposure to abuse in lesbian relationships (2.0%), the legal process (9.4%), how to deal with an abuser so as not to further endanger the woman (12.1%), health care and social services costs (13.3%), involving police (14.0%), and development of a safety plan (14.0%).
Students acknowledged a broad range of exposure to the issue of woman abuse external to the professional program curriculum. They most often reported learning about woman abuse through television, films, and videos (77.0%) and, secondly, through printed material including articles, books, and pamphlets (63.3%). Elective courses, including those in women's studies, were identified by 28.1% of the students as another means of learning about woman abuse.
Scores on the IBWB, in general, reflected sympathetic student attitudes toward woman abuse. According to Saunders (personal communication, August, 1993), scores on the three most reliable subscales, Wife Beating is Justified, Wives Gain from Beatings, and Help Should Be Given, can be combined to yield a general sympathy score. The mean score for nursing students was 32.64 (SD = 8.03), with no statistically significant differences found between program streams or levels. As well, the general sympathy score for nursing students, as a whole, did not differ at a statistically significant level from the scores for the other student groups surveyed.
Mean scores on each subscale for nursing students were as follows: Wife Beating is Justified 1.26 (SD = .29); Wives Gain from Beatings 1.47 (SD = .56); Help Should be Given 6.52 (SD = .43); Offender is Responsible 4.97 (SD = 1.13); and Offender Should be Punished 4.96 (SD = 1.21). Again, no statistically significant differences were found between students in different program streams or levels. Subscale scores of nursing students were not significantly different from those of students in the other programs surveyed with the exception that nursing students were more likely than occupational therapy students to see the offender as responsible and needing punishment. Nursing students generally scored as favorably, or more favorably, on the IBWB as have other groups tested previously using this questionnaire. These groups include psychology students, advocates for abused women, staff nurses and physicians in a teaching hospital, and medical and arts students at another Canadian university (McCaIl & Webber, 1994; Rose & Saunders, 1986, Saunders et al., 1987).
Despite these encouraging results regarding attitudes of nursing students, some specific findings merit attention. When scores on particular items were examined, it became apparent that some students had not resolved the issue of victim-blaming in that responsibility for the abusive behavior was not always definitively assigned to the abuser. Moreover, wife beating was justified by some students when a woman lies to her husband (9%), when a wife keeps reminding her husband of his weak points (8%), or if a wife breaks agreements (6%). These concerns become more consequential when the narrow, traditional definition of woman abuse used in the IBWB is taken into account. If students do not have sympathetic attitudes toward certain issues related to wife beatings, they are likely to be even less sympathetic to women in less traditional relationships who are physically abused or to women experiencing emotional or other nonphysical forms of abuse.
Conclusions and Implications
In this study, nursing students reported they had very limited exposure to the issue of woman abuse in formal curricular activities. Nevertheless, their attitudes tended to be sympathetic. It should be noted that students were not randomly selected and completion of the questionnaires was voluntary. Thus, students with a certain level of awareness and sensitivity to the issue may have been overrepresented in the sample. However, students are assigned at random to tutorial groups, and there was a high rate of compliance with completion of the questionnaires.
Limitations relating to the questionnaires are that the SEWAQ has not been widely tested and is a crude measure of exposure to the topic rather than of depth of learning. Also, when measuring attitudes, social desirability bias can create a response set. It is noteworthy, however, that Saunders et al. (1987) tested for this influence and reported that it was not a major contaminant of the IBWB subscales. The nursing students also found the wording of some items confusing, (e.g., "[hjusbands who batter should be responsible for the abuse because they should have foreseen that it would happen"), thereby further contributing to measurement error.
This study highlights the need for nursing education programs to determine the degree to which opportunities for learning about woman abuse are available to students. More specifically, the study helped to identify specific issues requiring attention in the nursing curriculum at McMaster University. To foster learning, it is important that students begin by identifying and exploring their own attitudes toward woman abuse. Examination of one's attitudes and critical analysis of how personal attitudes influence the ability to be therapeutic is essential. Attitudes are based not only on one's knowledge but also on deeply embedded values and beliefs (Hoff & Ross, 1993). Misconceptions must be confronted so that students are enabled to interact with women in a manner that is nonjudgmental. In particular, the notions of gender equity, valuing women for their contributions to society, and sovereignty of women over their bodies are important points for early discussion (Sampselle, 1991).
Although participants in our study were found to have sympathetic attitudes toward woman abuse, it is essential that the curriculum be designed to enhance knowledge and skills in specific content areas, including the identification of woman abuse, interventions, and referral. Development of skill in interviewing is an important consideration as nurse interviews have been shown to reveal higher rates of disclosure than self-report (McFarlane, Chistoff, Bateman, Miller & Bullock, 1991). Because the helper's response is "the most critical element in helping abused women" (Limandri, 1987, p. 11), it is important that nurses are able to respond in a manner which values women's experiences.
Additionally, students need to acquire an understanding of the societal forces that underlie the abuse of women. Linked to these broader social issues is the status of nursing within the health care system. Despite recent gains of the profession, nurses often still feel powerless in their roles (Hoff & Ross, 1993). Student nurses must be empowered so they can positively influence the health of victimized women and their families in their roles as service providers and advocates. Faculty support of student learning about woman abuse is critical. Educators need to be sensitized to and acknowledge woman abuse as a priority health problem and be able to effectively discuss issues of oppression as they relate to both abuse and the nursing profession. Opportunities for development of knowledge and skills will increase faculty comfort and confidence in teaching about the issue of woman abuse. Finally, faculty need to be able to create a safe environment for students' learning. Discussion about woman abuse often evokes strong attitudes and emotions, and statistically it is likely that some students will have personally experienced or witnessed abuse.
Unfortunately, the impact of inclusion of woman abuse in a nursing curriculum may be limited by other factors. It cannot be assumed that behavior in the clinical setting will necessarily be influenced by the acquisition of knowledge and skills and an appropriate attitudinal stance. Beliefs about the efficacy of interventions and work setting and health care system issues may be greater determinants of professional behavior on graduation than mere exposure during the education program (McCaIl & Webber, 1994).
Still, it is important that nursing programs critically examine the inclusion of woman abuse in their curricula so that nurses are adequately prepared to respond appropriately to the needs of their clients. Without structures in place which enable students to learn about this issue, they will not be adequately prepared to provide sensitive and appropriate care to women who have been intimidated by threat or force. Enhancing the attitudes, knowledge, and skills of future nurses is the beginning step. Nurse educators can make crucial contributions to the preparation of nurses who, because of their holistic focus and strategic placement in the health care system, can respond and not merely react.
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