Journal of Nursing Education

Nursing Curricula and Violence Issues

Margaret M Ross, RN, PhD; Lee Ann Hoff, RN, PhD; Ginette Coutu-Wakulczyk, RN, PhD



This article presents the findings of a survey of Canadian schools of nursing (N = 155) that determined the extent to which violence-related content is addressed in nursing curricula. The study yielded a response rate of 88%. Theoretical content regarding violence against children and women of all ages, and suicide as a response to abuse formed part of the curriculum of all schools of nursing, if only in readings. Child abuse and suicide received the greatest number of hours of instruction, followed by woman abuse, sexual assault, and elder abuse. University schools of nursing provided the greatest number of hours of instruction when compared with other types of schools. Schools in Western and Atlantic Canada provided the greatest number of hours of instruction on woman abuse when compared with other regions of the country. The majority of university schools provided experiential instruction in the area of violence, with the other types of schools providing very little such instruction. Findings revealed a sensitivity to the importance of including content on violence in nursing curricula; however, the approach to this content is largely incidental and heavily dependent on individual faculty interests. Implications of this study point to the need for the systematic inclusion of violence-related content and the sharing of resources among schools of nursing.



This article presents the findings of a survey of Canadian schools of nursing (N = 155) that determined the extent to which violence-related content is addressed in nursing curricula. The study yielded a response rate of 88%. Theoretical content regarding violence against children and women of all ages, and suicide as a response to abuse formed part of the curriculum of all schools of nursing, if only in readings. Child abuse and suicide received the greatest number of hours of instruction, followed by woman abuse, sexual assault, and elder abuse. University schools of nursing provided the greatest number of hours of instruction when compared with other types of schools. Schools in Western and Atlantic Canada provided the greatest number of hours of instruction on woman abuse when compared with other regions of the country. The majority of university schools provided experiential instruction in the area of violence, with the other types of schools providing very little such instruction. Findings revealed a sensitivity to the importance of including content on violence in nursing curricula; however, the approach to this content is largely incidental and heavily dependent on individual faculty interests. Implications of this study point to the need for the systematic inclusion of violence-related content and the sharing of resources among schools of nursing.

Preparing future nurses to address violence issues is an essential and challenging role for nurse educators. The power of nurses to make a difference to those who experience violence in their lives cannot be overstated. There is, however, both practice- and research-based evidence (Phillips & Rempushski, 1985; Ross, 1988) that nurses face difficulties regarding problem solving and decision making in situations of actual or potential abuse. The literature suggests that even the well-informed practitioner has limited direction and support in the struggle to effectively assess and intervene in situations where there is concern for the physical, emotional, or material safety and well-being of women and children. To fulfill their potential, students must be made aware of the prevalence of violence and provided with the opportunity to develop their knowledge, skills, and judgment to facilitate thensensitive and effective response to this serious public health issue. However, little is known about whether, and if so, how violence issues are addressed in schools of nursing. Consequently, the purpose of this study was to identify the extent to which violence-related content was included in Canadian nursing curricula. In addition, information was gathered about curricular approaches to the inclusion of such content and faculty needs for assistance with curriculum development and implementation. This article describes the findings and implications of the study for nursing practice and education.


The significance of this study derives from the prevalence of violence against women and children, its relationship to health, and the potential contribution of nursing to its prevention, detection, and amelioration. Additionally, this study is congruent with other societal initiatives at the local, provincial, national, and international levels that are directed toward ending violence against women and children.

The prevalence of violence against children and women of all ages as a social and public health problem has been amply documented since the 1960s by researchers, grassroots activists, and survivors (Burgess & Holmstrom, 1979; Kempe, Silverman, Steele, Droegemueller, & Silver, 1962; McLeod, 1987; Pizzey, 1974; Podneiks & Pillemer, 1989). Violence against women and children represents an abuse of power within family, trust, or dependency relationships. Striking at basic human rights, such violence preys on those who, because of their gender, age, disability, or dependence, are most susceptible to abuse. It encompasses killing, physical abuse, and sexual assault. It also involves other forms of abusive behavior including emotional abuse, financial exploitation, and neglect.

Whether violence against women and children is increasing, or rather being redefined and more zealously investigated without its basic pattern actually changing, is unclear. Nevertheless, the problem is significant in incidence (Johnson & Sacco, 1995; McLean, 1995; Pillemer & Wolf, 1986; Rodgers, 1994) and in its long-lasting physical and psychological effects (Hoff & Ross, 1993). Serious health implications include feelings of helplessness and vulnerability; problems with self-esteem; a high incidence of addictions, eating disorders, and psychosomatic symptoms; pregnancy as a vulnerable period for the cycle of assault to begin for women; and depression as a coping mechanism and chronic reaction.


Nurses are in an ideal position to contribute to prevention, detection, and effective intervention in situations of potential or actual violence against women and children. Because of their sheer numbers, the variety of their practice locations, and the nature of their practice, nurses are in close contact with a large segment of the population at risk for violent episodes. There are 264,932 registered nurses in Canada working in diverse health care settings, in public schools, and most important, in people's homes (Statistics Canada, 1994). As a frequent point of first contact with the health care team, nurses are strategically situated to mobilize resources and initiate intervention. The scope of nursing (practice, education, and research) is congruent with intervention at the primary (prevention), secondary (screening & treatment), and tertiary (rehabilitation) levels of prevention.

At the primary level of prevention, nurses can engage in educational programs that heighten awareness of violence against women and children. Such programs can help reverse the victim-blaming tradition and re-enforce the current clinical emphasis on holding perpetrators accountable for their violence (Hoff, 1995a). Nurses can participate in establishing policies and procedures that protect the rights of individuals and families within community and care faculties. They can also engage in research aimed at determining the antecedents and consequences of interpersonal conflict and violence, testing the validity and reliability of assessment tools (Hoff & Rosenbaum, 1994), and evaluating clinical interventions for their efficacy in solving problems associated with violence. At the secondary level of prevention, nurses are in a unique position to establish screening programs for individuals at risk, participate in the medical treatment of injuries resulting from violent episodes, and coordinate community services in an effort to provide continuity of care. At the tertiary level, nurses can facilitate the healing and rehabilitative process with ongoing counseling of individuals and families and support to survivors in their efforts to achieve an optimum level of safety, health, and well-being.


Violence is a problem of concern to everyone. In Canada, this concern is evident at both federal and provincial levels of government. At the federal level, over the past 15 years, there have been many initiatives related to violence against women and children. Among these, a 4-year federal initiative (1991 to 1995) provided $136 million through seven departments and agencies to address the problem of societal violence. This initiative was aimed at preventing violence and improving community responses to survivors, particularly in the health and social service fields. In a July 1993 report of a 2-year study, a federal panel maintained that violence was at a crisis level (The Canadian Panel on Violence Against Women, 1993). The report listed more than 500 recommendations including a plea for mandatory education for health professionals to ensure that they are prepared with the essential knowledge, skills, and attitudes to effectively work with victims of violence.


It is crucial that nurses are knowledgeable about the prevalence of violence, able to recognize violence-related needs at an early stage, and deal effectively with them at the level of the individual, family, and community. Yet, a 1992 survey of Ontario schools of nursing revealed that most nursing curricula do not include a systematic approach to violence-related content (Hoff & Ross, 1995). Findings revealed that the topic of violence presents a greater than average challenge to educators and clinicians charged with teaching and role modeling on this practice issue. In addition, curricular change is fraught with challenges that include, but are not restricted to, the knowledge and technology explosions that demand attention in the preparation of nurses, the danger of an "add-on" response to each new request for new content, and the collusion of health professionals (if only by silence and inattention) in the traditional definition of violence as a private issue, rather than a public one (Ross & Hoff, 1994).

Despite these challenges, however, nurse educators increasingly are addressing violence as a public health issue. Building on public health approaches to education, there appears to be more explicit attention to the topic in curriculum development and implementation. The study reported here, for example, was one of several initiatives undertaken to address the issue of violence in nursing education. The first project resulted in the production of a curriculum guide for nursing entitled, Violence Against Women and Children (Ross & Hoff, 1993). This guide emphasizes the centrality of social, political, and gender issues in shaping not only the experiences of survivors of violence but also the professional responses of nurses. The guide also offers approaches to systematically include violence-related content in nursing curricula. These approaches were addressed throughout the province of Ontario in a series of workshops involving collaboration among faculty, clinical preceptors, and community-based experts in victim-survivor care (Hoff & Ross, 1995).

In the United States, McBride (1992) noted that violence has been a relatively neglected dimension of nursing curricula and made a plea for increased consideration of the topic as a major area of study by nurse educators. Campbell (1992) further recommended that student nurses learn about violence in carefully planned programs that take into consideration various ways of knowing and experiential learning. Only one study (Kerr, 1992) reported on the integration of violence as a content area in an undergraduate program in nursing at a university. The author described curricular objectives that were met within the context of courses in human development and psychosocial nursing. In addition, placements in outpatient settings such as safe houses, crisis intervention centers, and inpatient and outpatient chemical abuse treatment programs and psychiatric services provided students with the opportunity to test and further develop their knowledge and skills in the practice field.


There has been considerable debate about the theoretical underpinnings of violence and abuse against women and children (Dobash & Dobash, 1979; Hoff, 1995b; Segal, 1987). Underlying assumptions regarding the development of nursing curricula include the need to be relevant and accountable to critical sectors of society. Direction for this study was derived from global concerns regarding violence and abuse. The study was also based on the evidence of the past 3 decades, revealing abuse across the life span, including the abuse of children, women, and older adults. Concepts of crisis prevention and intervention also guided this study, especially nonviolent conflict resolution and the interrelationship between victimization and the risk of suicide and assault on others as a response to abuse. In addition, two key features of professional education, i.e., the centrality of experiential learning and the integration of theoretical content, provided direction for the study (Ross & Hoff, 1995).


This study was conducted as a result of a curriculum development project funded by the Ontario Ministry of Colleges and Universities. The overall objective of that project was to develop a curriculum guide for nursing to facilitate the systematic inclusion of content on violence against women and children in nursing education programs (Hoff & Ross, 1993). A survey of Ontario schools of nursing (N = 43) regarding inclusion of such content, plus a series of focus groups with key people, provided the database for development of the guide. On request to replicate the Ontario survey in the United States, Woodtli and Breslin (1996) collaborated in our minor revision and expansion of the tool. Subsequently, this survey was extended to all Canadian schools of nursing.


In addition to the 43 Ontario schools already surveyed, another 112 Canadian schools of nursing were surveyed over a period of 1½ years. The lengthy survey period was influenced in part by the necessity of instrument translation for use in the majority of Quebec schools where the language of instruction is French. A total of 155 questionnaires were distributed to deans and directors in all regions of Canada, including the Yukon. They were asked to select the faculty member they considered most knowledgeable about their curriculum to respond to the questionnaire. Respondents held administrative positions either at the dean or director level or were program managers, curriculum coordinators, or chairpersons of curriculum committees. The initial survey of Ontario's schools yielded a response rate of 93%. The response rate was 87% for schools in Western Canada and the Yukon (JV = 38), and in Atlantic Canada (N = 20) the response rate was 95%. Among the 4 anglophone and 50 francophone schools in Quebec, the response rate was 76%. The cumulative response rate among schools in all Canadian provinces was 88%.


The 35-item survey instrument was developed particularly for this study, following its original use in the Ontario curriculum development project noted earlier (Ross & Hoff, 1993). The questionnaire consisted primarily of fixed-choice questions (with options for comments) and several open-ended questions. Prior to distribution, items were reviewed for content validity by three experts in the field of violence, and slight modifications were made to enhance comprehension and increase specificity of response. The survey tool was designed to gather demographic data about programs of nursing including the type of program(s); the number of students enrolled; and the number, employment status, and academic preparation of faculty. The Ontario survey focused on the dimensions of child abuse, woman abuse (by domestic partner), and elder abuse. The remaining surveys (Western, Atlantic, and Quebec regions) also included questions about sexual assault, crisis, and suicidal behavior as a response to victimization. Questions were asked about the number of hours of classroom instruction devoted to the content, the title of the course in which the content was taught, and the academic preparation of the faculty member responsible for the content. The last items referred to curriculum development and faculty perceptions about the adequacy of attention to violence-related content, the need for assistance in curriculum development, and the status of current curriculum planning and revision.


TABLE 1Hours of Instruction by Region


Hours of Instruction by Region


Demographic Characteristics of Schools of Nursing

Approximately one third of responding schools were from Ontario (31.6%) and Quebec (30.1%), the two largest provinces in Canada. Schools in Western Canada (Yukon, British Columbia, Alberta, Saskatchewan, and Manitoba) represented 24.3% of the sample, and Atlantic Canada (Newfoundland, Nova Scotia, New Brunswick, and Prince Edward Island) comprised the remaining 13.9%. There were four categories of schools represented in the study:

* Universities (21.3%).

* Community colleges (41.1%).

* Cegeps (colleges educational generale et professional, a particular type of community college in Quebec; 25%).

* Hospital-based schools (12.6%).

Universities were located in all of the provinces. Community colleges were found in all regions with the exception of Atlantic Canada. Hospital schools of nursing were located in Alberta, Manitoba, and Atlantic Canada. The majority of schools (66%) offered diploma programs in nursing. They were followed in frequency by those offering baccalaureate (22%) and master's programs (10%). While the majority (61%) reported enrollments of between 100 and 400 students, approximately 20% reported enrollments of less than 100 and more than 400 students.

The majority of schools (61%) employed between 11 and 30 full-time faculty, with a small proportion (12.5%) employing less than 10, and 22% employing more than 30. All schools aleo employed part-time faculty. Nearly half (49%) were small schools with less than 5 part-time faculty members. Twenty-one percent hired between 6 and 10, and 22% hired more than 11 part-time faculty. With respect to the academic preparation of faculty, approximately one third of the schools reported that more than half of their faculty were master's prepared; whereas, only 3% reported that more than half of their faculty were doctorally prepared. Nevertheless, approximately one quarter of schools reported at least 25% of their faculty studying towards a master's degree, and 6% reported at least 25% of their faculty studying towards a doctoral degree.

Theoretical Instruction

Theoretical content related to violence was reported as part of the curriculum in all schools of nursing. The mean number of hours of instruction allotted to the five dimensions of violence was: child abuse (4.0), suicide (4.0), woman abuse (3.6), sexual assault (3.4), and elder abuse (2.7). There were several schools that used only readings to address issues of violence. Two used this method to address woman abuse, 3 to address child abuse, and 16 used only readings on the topic of elder abuse. Elder abuse received significantly fewer hours of instruction and curricular attention when compared with child abuse and woman abuse (t = 23; df= 135; p = .000) and with suicide and sexual assault (t = 27; df= 91; p = .000).

Theoretical Instruction by Region

There were similarities and differences in hours of theoretical instruction according to region (Table 1). In the area of child abuse, the four regions were very similar with respect to hours of theoretical content. The mean number of hours of instruction varied between 3.9 and 4.2, with Ontario reporting the least and Atlantic Canada reporting the greatest attention to child abuse. The regions were also similar with respect to suicide, with mean hours of instruction varying from 3.9 to 4.3, with Atlantic Canada leading the way and Quebec trailing.

In the other areas surveyed, however, the regions differed significantly. Mean hours of instruction for sexual assault varied between 2.9 and 3.9, with Western Canada reporting the greatest number of hours and Quebec reporting the least. In the area of elder abuse, mean hours of instruction across the country were also statistically different. Quebec reported the least number of hours of instruction devoted to elder abuse, and Western Canada reported the greatest. Similarly, in the area of woman abuse, Western and Atlantic Canada provided significantly more hours of instruction than Ontario or Quebec.


TABLE 2Hours of Instruction by Type of School


Hours of Instruction by Type of School

Theoretical Instruction by Type of School

There were differences according to type of school with respect to mean hours of theoretical instruction in four out of the five content areas (Table 2). Universities provided significantly more theoretical content regarding child abuse, woman abuse, elder abuse, and sexual assault when compared with community colleges, cegeps, and hospitals. In the area of suicide, however, significant differences did not emerge. Hours of instruction varied between 3.9 hours for hospital programs and 4.4 hours for community colleges. This was the only content area in which universities did not lead the way with respect to hours of instruction.

Experiential Instruction

In large measure, schools of nursing throughout the country provided little planned experience with abused women and children. The largest proportion of schools providing such experience (21%) was in Atlantic Canada. This was followed by 18% in Western Canada and 14% in both Ontario and Quebec. When analyzed by type of school, differences emerged between universities and other types of schools. Close to two thirds (62.1%) of universities provided for planned clinical experiences in assessment and care of survivors. A much smaller proportion of community colleges (3.6%) and hospitals (11.8%) provided for such experience. None of the cegeps reported providing planned clinical experience.

Despite these findings, a substantial proportion of schools (41%) reported that students had coincidental or voluntary opportunities for clinical practice with clients who had experienced violence in their lives. Such experiential learning occurred in mental health and psychiatric settings, prisons, clinics specializing in sexually transmitted diseases, and children's hospitals. One respondent from a school with a graduate program reported that several graduate students had conducted their thesis research in the area of violence against women, including abuse against nurses. Only one respondent noted that some students had their own personal experiences with violence in that they had come from or were in relationships that were abusive in nature.

Content by Type of Course and Faculty Preparation

Respondents cited more than one course title in which each of the content areas was addressed. In addition, they reported that, with the exception of child abuse and suicide, the majority of faculty members who addressed each content area had not received specialized academic preparation in that particular area of violence. Most of the content on child abuse was included in courses related to the nursing of children (60.3 %) and taught by faculty with academic preparation in the area of child health (56.6%). Close to one third (27.9%) reported that child abuse was included in psychiatric nursing and taught by faculty with preparation in mental health (30.1%) but not in child health.

The topic of woman abuse was included in a wide variety of courses including psychiatric nursing (30.9%), maternity nursing (21.3%), adult health (16.2%), community health (10.3%), women's health (10.3%), and medicalsurgical nursing (10.3%). Nearly half of the faculty who addressed woman abuse were academically prepared in psychiatric nursing (47.8%). The topic of elder abuse was, in large measure, addressed in gerontological nursing (46.3%) by faculty who were prepared in gerontology (41.9%), while a substantial proportion of this content was addressed in psychiatric nursing (22.8%) by faculty who were prepared in psychiatry (36.8%). Sexual assault was addressed primarily in psychiatric nursing (43%), adult health (12.9%), and a variety of other courses by faculty who were prepared in psychiatric nursing (43%), maternal child nursing (23.7%), and adult health (10.3%). Suicide was primarily addressed in psychiatric nursing (81%) by faculty who were prepared in psychiatric nursing (79%).

Curriculum Development and Implementation

Although only one third of respondents indicated that they were in the process of curriculum revision, these responses may have been influenced by the occurrence of school closings and amalgamations that were reported incidentally in the data. The issue of curriculum development, review, and revision may have been framed within the context of social, political, and economic changes that were having a strong impact on nursing education throughout the country at the time of the study.

Close to half of the respondents (48%) believed that their curriculum adequately addressed violence-related content, and the remaining were almost equally divided between believing this was not the case (28%) and being unsure (24%). Those who were unsure qualified their statements by noting that because it was only incidentally threaded through the curriculum the adequacy of the content was difficult to evaluate. The primary reasons given for inadequate curricular attention to this topic were insufficient time and too many other priorities requiring attention. Other reasons included the fact that the topic had not been identified as core content and, therefore, had not been threaded into the curriculum, and that no one had assumed ownership or responsibility for the content. One respondent described the curriculum as practice driven and reported that if situations related to violence arose in practice, they would be addressed in class and conference time.

Respondents reported a variety of conceptual frameworks providing the theoretical underpinnings of their curriculum. These included Sister Caliste. Roy's adaptation model (Andrews, 1991), Henderson's (1991) needs approach, the Orem (1991) self-care model, Leininger's (1995) transcultural model, NANDA (Rantz & Lemone, 1995), King (1981) and Newman's (1994) system model, and others. A few respondents noted that several models were used in their curriculum, and some identified theoretical pluralism as providing the foundation for their curriculum. Several reported that they developed their curriculum around concepts related to maturation and stress, empowerment, or health promotion, and four respondents reported that they did not use a specific nursing theory. There were no schools reporting a feminist theoretical framework. Only one respondent referred to how their theoretical framework served to inform the inclusion of content related to violence. This respondent reported that the unit of study was the family, whose work is to engage in health promotion activities. In this curriculum, violence was viewed as a serious abuse of power in family, trust, and dependency relationships and was discussed within a framework of situational and developmental crises.

In response to whether they would be interested in a workshop to increase their knowledge and skill with respect to the topic, half of the respondents (50%) indicated they would be interested. Respondents stated that the primary learning need was to change attitudes about the importance and relevance of violence-related content and the application of knowledge in clinical situations. In addition, respondents indicated a need for an overview of essential content regarding violence, assistance with curriculum redesign, the development of teaching strategies such as case studies or clinical scenarios, and the establishment of clinical learning opportunities within health and social services designed especially for those who have experienced violence in their lives. Several respondents indicated the need for more contact with victims, survivors, and grassroots activists. Respondents also noted the need to more formally record content included in clinical conferences, suggesting that issues of violence emerging out of clinical experience may be addressed but are not accounted for in curriculum audits and assessments. Although the use of lectures appeared well entrenched in schools of nursing, faculty were attempting to move from lecture-based teaching to more interactive approaches such as seminars and problem-based learning for the delivery of nursing curricula.


Findings from this study are encouraging in that all schools of nursing reported that they addressed, in some way, issues related to violence against women and children in their curriculum. The overall response rate of 88% provides confidence that most students of nursing in Canada are at least introduced to the topic of violence as a serious public health issue of societal concern through their curriculum, if only in readings. Child abuse and suicide received the greatest attention when compared with other types of violence. This finding reveals the parallel between nursing education and societal responses to victimization. Awareness of child abuse began in the 1960s. Corresponding to this pattern, child abuse was the most consistently and appropriately addressed area of violence in all schools of nursing. Similarly, psychiatric nursing has always addressed suicide as a curriculum issue. It may be that these topics fit well within traditional curriculum models in which pediatric and psychiatric nursing have always formed an important part of nursing curricula. In large measure, the issues of child abuse and suicide were addressed in courses entitled pediatric and psychiatric nursing by educators who were prepared in these fields. Although our question about suicide was contextually framed as "self-injury as a response to victimization," further research is needed to ascertain the extent to which the traditional treatment of suicide by nurse educators includes its widespread connection to histories of abuse, especially among adolescent girls and women (Stephens, 1985).

There are several findings, however, that are less encouraging. Woman abuse and sexual assault received less curricular attention than did child abuse and suicide. This was somewhat surprising given the explosion of knowledge and increase in public attention to these issues in recent years. It may be that the restructuring of curricula is not yet reflective of societal changes whereby incidents of violence against women including sexual assault are now recognized as a serious social and public health issue. It may also reflect the neglect of nursing curricula in addressing gender and power as social determinants affecting the health and well-being of women. In addition, much of woman abuse and sexual assault was addressed in psychiatric nursing, reflecting the traditional interpretation of this issue in terms of psychopathology rather than as a public issue of gender inequality and the abuse of power. Finally, elder abuse received the least curricular attention and was the topic most frequently covered only in readings. This finding was surprising because there has been much rhetoric recently regarding the inclusion of gerontology in programs of nursing. Nevertheless, gerontology as a special area of practice continues to be underrepresented in nursing curricula and, therefore, it is not surprising that abuse of older adults is also underrepresented.

Regional findings revealed that the Atlantic and Western Canada schools provided more hours of instruction on child abuse, woman abuse, elder abuse, and sexual assault than either Ontario or Quebec. It is also clear that students were provided with few opportunities for experiential learning in the area of violence. Although Atlantic Canada led the way in providing experiential learning, only 21% of their schools actually provided this type of learning opportunity. In addition, although universities provided significantly more opportunities for planned experiential instruction than other types of schools in all areas of violence except suicide, they comprised only 21% of all schools of nursing in Canada. University schools of nursing have historically provided a great deal more emphasis on public health nursing and nursing in the community when compared with other types of schools. Nevertheless, violence occurs within hospitals and other institutions where college and hospital students receive the bulk of their learning; yet, the issue of institutional violence does not appear to be a major curriculum focus for these schools. Our findings resonate with Eisner's (1985) concept of the "null curriculum" (p. 97), referring to what is missing from the curriculum or what things are left out. Finally, despite the prevalence of violence among women and children, it was remarkable that only one respondent noted that some students themselves had experienced violence in their lives and suggested the need for a planned coordinated response for such students.


Findings from this study provide direction for nurse educators who are striving to render their curricula relevant to current health, social, and political realities that include the existence of interpersonal violence. There is a need for increased, systematic curricular attention to issues of violence against women and children. Although it is beyond the scope of this article to discuss all the content required by nurses, suffice it to say that without a sensitivity to the political reality of the societal devaluation of women and children and a knowledge of the influence of gender and power differentials on health and well-being, students will be at a major disadvantage in their practice, and the health and well-being of women, children, and entire families will be compromised. In addition, if students' own possible experiences with abuse and self-care issues are not factored into the total equation, the disadvantages for both clients and providers are compounded. Because no single discipline holds the key for solving the problems and meeting the needs of women and children who enter the health care system, the principles of interdisciplinary training must be integrated into all curricular initiatives (Hoff, 1995b; Tilden et al., 1994).

There is also a need to avoid fragmentation and duplication of efforts. For example, the inclusion of violencerelated content in a wide variety of required courses in the entire curriculum may result in the false belief that the topic is addressed elsewhere and, therefore, neglected in relevant nursing courses; alternatively, duplication of efforts may result. Findings from this study underscore the need to ensure that violence issues are adequately included in the curriculum at large and that the content of various courses addressing violence issues builds on and supports other courses.

Students must have the opportunity to demonstrate competence at each level of the learning process, Such a curriculum requirement necessitates the valuing of experiential learning and the selection of appropriate approaches to teaching and learning at each level. The issue of violence against women and children is not just a theoretical concept but a major practice issue. Given that nursing is a profession that is theoretically grounded in practice (Hooten, 1976) and that nursing knowledge is embedded in practice and accrues over time (Benner, 1984), it is crucial that students encounter clients who have experienced violence in their Uves, engage in collaborative decision making with them, and carry out tasks and interventions under the supervision of specialists in education and practice. Only in this way will they be prepared to enter the workforce as an advocate of women and children with at least an awareness of the prevalence of violence and the beginning skills to respond appropriately. In short, it is time to move from rhetoric to curriculum action, from elective to required content on which students are examined, from the null curriculum to explicit inclusion of content that is warranted by overwhelming epidemiological evidence. For example, the history of battering among pregnant women is at least 25%, as compared with gestational diabetes rates between 2% and 6%; yet, teaching about the latter is much more routine than the former (Hoff & Ross, 1993).

There is also a need for faculty to share resources and develop strategies for gaining expertise in particular areas. It is unreasonable to expect all faculty members to be expertly prepared in all areas of violence against women and children. Developing relationships with other schools of nursing, establishing courses that meet the needs of several schools (e.g., through distance education), and capitalizing on the expertise of individual faculty members can serve to conserve and extend resources already available. Collaboration with grassroots workers and community activists in providing a wide variety of learning opportunities for students can also serve to ground their learning in the real-life experiences of women who experience violence in their lives. Many of these individuals speak movingly and discuss their situation within a feminist perspective, which is still not a comfortable topic for many faculty and students of nursing.


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