COMMUNITY
AND PUBLIC HEALTH NURSING
PRACTICUM
31 Teen
Pregnancy: prevention, community support services.
After studying this chapter, you should be able to:
·
Describe teen
pregnancy?
·
Describe why do
teenage girls get pregnant?
·
How to stay healthy
during pregnancy?
·
What's contraception? Identify different kinds of
contraception.
·
Analyze the
nurse's role in prevention and detection of violence.
Each year, more than 1 million
American teenagers become pregnant. There is a strong association between young
maternal age and high IMR, and infants born to teenagers are at increased risk
for preterm delivery, neonatal, and postneonatal mortality (Jolly et al.,
2000). Infants born to African-American adolescents are more likely to be LBW
babies than are infants of white teens. Infants born to very young adolescents
(aged 10 to 14 years) are at very high risk for neonatal mortality. Teen
mothers have increased psychological risks, such as isolation, powerlessness,
depressive disorders, lowered self-concept, and increased somatic complaints.
Developmental and maturational processes are disrupted or compromised; and
young mothers face diminished prospects for completing their education. The
markers for successful pregnancy outcomes and future life events are more
complex. The mother’s educational attainment, marital experiences, subsequent
fertility behavior, labor force experience, occupational attainment, and
experiences with poverty and public assistance are all directly related to the
adolescent pregnancy. The issues of adolescent parenting are complex. They
encompass many areas, including emotional, physical, and social issues. The
community health nurse has a unique challenge when teaching teens about
pregnancy-related changes, accompanying needs, and preparation for the
important role of parent to the infant..
Introduction
Pregnancy
occurring in young women between the ages of 13 and 19.Most teenagers don't plan to get pregnant, but many
do. Teen pregnancies carry extra health risks to the mother and the baby.
Some statistics facts:
·
18%
of U.S teens have experienced sex prior to the age of fifteen
·
66%
of unmarried teens have sex by the age of nineteen years
·
By
age twenty 75% of American females and 86% of American males are sexually
active
·
·
By
age twenty 40%of white women and 64% of black women will have experienced at
least one pregnancy
·
80%
of teen women who get married most likely get divorced
·
About
1 million teenagers become pregnant each year, and more than 530,000 give birth
·
3
million out of 12 million teens are affected by sexually transmitted diseases
these diseases can cause complications with the baby
·
9%
of teenage girls have low-birth weight babies
·
50%
of adolescents who have a baby become pregnant again within two years of the
first birth
·
The
second baby born to an adolescent mother is at risk than the first baby to be
low birth weight
·
The
children of adolescent mothers are at increased risk than the first baby to be
low birth weight
·
The
children of adolescent mothers are at risk for being a teen parent themselves
·
Every
26 seconds another adolescent becomes pregnant
·
Every
56 seconds another adolescent gives birth
·
85%
of all teenage pregnancies are unplanned
·
13%
of all
·
80%
of teenage pregnancies occur outside of marriage
·
9
million children living in welfare families
·
The
fathers born to teenage mothers are likely to be older than the women
·
Teenagers
account for 31% of all non-marital births
·
The
younger the mother the greater the risks of complications for both mother and
child
·
2/3
of never married mothers now raise their children in poverty
·
Children
of teen mothers are far more likely than the children of older, two parent
families to fall behind and drop out of school. Their also at risk of getting
into trouble with the law, to abuse drugs and join gangs, to have children of
their own out of wedlock, and to become dependant on welfare.
·
The
majority of all teens in the
·
1/4
of all unintended teen pregnancies occur to adolescents using no birth control
·
Approximately
70% of all pregnant adolescents do not receive adequate prenatal care, when in
reality, they are the group that needs care the most
·
Recent
studies reveal that up to 2/3 of teen mothers have a history of sexual abuse
·
School
failure (not in all cases) often follows early childbearing, pregnancy, and
sexual intercourse
·
Teens
often have poor eating habits and may smoke, drink alcohol, and take drugs,
increasing the risk that their babies will be born with health problems
·
Pregnant
teens are least likely of all maternal are groups to get early and regular
parental care
·
1/3
of teens moms drop out of school
Emotional Needs. Teenagers who become pregnant deal
with this change in their life in a variety of ways. Some have such a strong
denial system that they deny the pregnancy, even to themselves. It may take 3
or 4 months into the pregnancy before they can admit it and seek out a
physician’s diagnosis. Often, their parents are the last to know. What is
difficult about this scenario is that prenatal care is delayed into the second
trimester of pregnancy. If the teen chooses to continue with the pregnancy, the
delayed prenatal care could compromise the well-being of both the young mother
and the fetus. What the teen needs at this time is supportive caring parents
and professionals. Teen parents have difficult choices to make; most continue
with the pregnancy, although some may later choose to give the baby up for
adoption. Others choose abortion. These choices are difficult and are fraught
with emotion. Supportive parents along with their teens, in consultation with
professionals, can explore all options. This may be the time that the community
health nurse first begins to work with the teen, perhaps at school in a school-based
clinic. First contact may also occur in a clinic or physician’s office, or on a
home visit resulting from a referral from a health care provider. The nurse can
offer educational services, emotional support, and referrals for services as
needed. Adolescent parenting programs set up in some communities have positive
effects. In one program, paraprofessionals indigenous to the community made
intensive home visits to pregnant teens. This program, implemented by a
visiting nursing service, demonstrated that mentorship and social support
improved pregnancy outcomes by reducing the percentage of LBW babies born to
participating teens to 4.6%, compared with the national average of 13.5%
(Flynn, 1999). The goal of any pregnancy is positive maternal–infant outcomes,
including a positive relationship. For some teen mothers, positive
relationships are more difficult to achieve than for older mothers. The
importance of positive relationships and self-esteem has an impact on the
quality of mothering and positive responses to infant distress. Typically,
older adolescents have higher self-esteem than younger mothers do; this was
observed in classic studies by Olds and colleagues (1999; 2000) and by
Koniack-Griffin and colleagues (2000; 2002; 2003). These significant studies
demonstrated the benefits of intensive intervention programs. Community health
nurses who have special training are able to provide each participant with
services that promote overall health of the mother and maternal-infant bonding.
Results of these studies can guide nurses in their work with pregnant
adolescents.
Physical Needs. Pregnant teens have a gamut of physical needs that can
be addressed by routine prenatal care and education, but there is need for
continuity if such endeavors are to be successful. Routine prenatal care is one
of the most important needs, and teens may require assistance in recognizing
the value of monitoring the pregnancy. Some may feel embarrassed and
uncomfortable with male health care providers and refuse to keep appointments.
If she is able to make her discomfort known, adjustments can be made so that
the teen is seen by female professionals or is allowed to bring the baby’s
father or a girlfriend. Whatever it takes to get the teen to prenatal
appointments should be encouraged, including making arrangements for
transportation—procuring bus tokens, calling a taxi, or arranging for a friend
or social worker to drive the teen to her appointments. The pregnant teen needs
education regarding changes in her emotional state and her body, the growth and
development of the fetus, dietary requirements, rest and relaxation needs, and
anticipatory guidance for infant caregiving and parenting. Teaching can take
place as part of each prenatal appointment, in specific classes at school for
pregnant teens, in the health department clinic, or during home visits. In each
setting, the community health nurse can modify the teaching methods to the
setting and the individual needs of the teen. Changing teen behavior during
pregnancy can be challenging. The community health nurse may focus on one
important and seemingly less complex issue of nutrition during pregnancy.
However, it is a more difficult task to change the eating habits of teens than
it is with adults. In their stage of development, they usually are more
concerned with body image than with fetal growth and development. Fad diets,
peer pressure, and personal control are all issues with which the pregnant teen
is struggling. If a teen has been raised in poverty, a multiplicity of other
issues can affect her motivation to make dietary changes during pregnancy.
Social Needs. Pregnant teens are dealing with two stages of their
own growth and development at the same time, which makes their social needs
complex. They are struggling with the normal adolescent challenges along with
the responsibilities of pregnancy and parenting (young adulthood stage of
development). There may be changes in acceptance by social groups or in types
of activities (eg, surfboarding, mountain climbing). The group may participate
in activities that the pregnant teen should not participate in, such as
smoking, drinking, or taking illicit drugs. This causes conflict for a pregnant
teen who has a strong need to be accepted by her peer group and also knows that she has a responsibility to her
unborn child. The community health nurse can help the teen solve her dilemma by
providing a social support system among the attendees at prenatal classes. The
nurse can also convince the teen’s parents or other adults in her life to offer
her more support. Often, a developmental crisis such as a teen pregnancy can
help cement the mother–daughter relationship. It takes time and work on the
part of the parents and the teen. The teen will need the support of her parents
after the baby is born, and strengthening the relationship during pregnancy is
an important start. Another social outlet and an important resource is school.
The teen should be encouraged to continue her studies, with the goal of
graduation. The health and welfare of children are related to the educational
levels of their parents. Higher educational levels increase the likelihood that
children will receive adequate medical care and live in a safe and supportive
environment with adults who are responsive to their needs (Koniack-Griffin et
al., 2000).
Why do teenage girls get pregnant?
·
Some girls have not been educated on right and wrong birth control methods
·
Some girls, although
very rare, feel that becoming pregnant is a good way to rebel against her
parents
- Some girls are missing love and other emotional
feelings because they are not getting it at home, so they look for those
feelings elsewhere in order to fulfil their needs
- Often, mistakes do happen (the condom is broken;
she forgot to take her pill one day etc.)
- Some girls feel the need to have control when
they loose control everywhere else
- Some girls feel that if the have a baby, her
boyfriend will lover her and stay
- Some girls get pregnant because becoming pregnant
is very important in their culture
Why
don’t teenage girls want to get pregnant?
- Some girls feel that they are not emotionally,
physically, and financially ready to raise a child
- Some girls are afraid of the pain that comes with
child labor
- Some girls are concerned about their health and
the health of the baby if she were to have it
- Some girls believe that pregnancy will destroy
their future plans and goals
- Some girls believe that they are too young
- Some girls can't handle all of the responsibility
that comes with pregnancy
- Some girls don't want to loose their social life
- Pregnancy disturbs the academic life of a
teenager
- Some girls are afraid that their partner will
leave her and the child
- Pregnancy is often against the regulations of
religion if you are not married
- Some girls believe it's against their values and
morals
- Some girls with STI's and HIV don't want to pass
it on to their children or endanger the child's good health
- Some girls are afraid that their parents would
become highly upset and ashamed of them if they get pregnant before they
accomplish their goals or get married
What
kind of help does a teenage mother need?
- Teenagers that become pregnant need the same help
that an adult woman would need. Teenage girls have the same symptoms that
adult women have like nausea, vomiting, fatigue, and breast tenderness.
- Even though pregnant teenagers are treated the
same way as adults, teenage girls need more emotional and psychological support
- Teenage girls need extra help, encouragement, and
guidance as they make the transition from pregnancy to parenthood
- Teenage girls need loved ones such as friends and
family to help her set realistic goals for her future and the future of
her child as well as her job and school opportunities
- All of these are very important and needed for
future healthy lives of the child, father, and mother.
Health Risks to the baby
A
baby inside of a woman's womb depends on its carrier greatly. A baby born to a
teenage mother is more at risk than a baby born to a grown woman.
- 9% of teen girls have low-birth-weight babies
(under
- Low birth-weight babies may have organs that are
not fully developed. This can lead to lung problems such as respiratory
distress syndrome, or bleeding in the brain
- low birth-weight babies are 40x more likely to
die in their first month of life than normal weight babies
- Low birth-weight babies may have immature organ
systems (brain, lungs, and heart), difficulty controlling body temperature
and blood sugar levels, and mental retardation. Low birth-weight babies
have a higher risk of dying in early infancy than among normal weight
babies
- Low birth-weight babies are exposed to mental
retardation, brain damage, and injury at birth
Health
Risks to a Teenage mother
A teenage mother has special problems, emotionally and
physically
- The death rate from pregnancy complications is a
lot higher for girls who are pregnant under the age of 15 than among older
teenagers
- Pregnant teenagers are more likely to be
undernourished and suffer premature or prolonged labor
- During the first 3 months of pregnancy; seven out
of ten teenage girls do not get prenatal care, see a doctor, or go to a
clinic
- Teenage mothers are at risk of getting anemia,
high blood pressure, placental problems, and pregnancy induced
hypertension
- Teenage girls with STI's or HIV can pass
complications on to her baby when it is born
- Teenage girls may also develop many emotional
problems such as depression, shame, guilt, and stress
- Teenage mothers have the risk of problems such as
poor weight gain, premature labor, and other complications. *The younger
the mother, the greater the chance to have complications for both the baby
and the mother.
Consequences
of Teenage Pregnancy
The
future of teenage girls who are pregnant often don't hold great promises for
the baby and teenager due to the amount of dedication involved with raising a
child
- 2/3 of pregnant
teenagers drop out of school
- The demands of
education are high in order to find a good job, therefore leaving a
problem for a teenage mother who has dropped out; leading her to go on welfare
because of her deep financial problem
- If a teenage couple
get married after they have a baby, it will most likely end in divorce
- A teenager cant go
out with friends as much as they used to, their social life is put on hold
for quite a while
- Teenage girls who
are pregnant cant party (drink, smoke, and use drugs)
- Teenage girls miss
out on their own childhood because they are busy taking care of another
child
- Teenage girls put
pressure on their parents for help on raising the child
- Children miss out on
many things an older mother can give to her child
- Due to a teenagers
young age, they do not have the proper parenting skills that are needed in
order to raise a child well
- Staying in school
can be harder due to the schools attitude, peer attitudes, and lack of day
care for the baby
What to do with an unwanted pregnancy
Even though many women plan their pregnancies with their mates, many women
don't. Mistakes do happen because we are only human, but just because we are
human does not mean we can't take responsibility. After weeks of being
pregnant, it is too late to try to prevent the pregnancy. Many women keep their
babies while others put them up for adoption with other parents. Other teenage
girls may choose that abortion is the right choice for them. There are many
places and resources where they will help pregnant teens make the right choice
for the baby and the mother.
Steps to take if you are pregnant:
1. Talk to someone you can trust
2. Overcome the sense of shame and guilt that you
may feel because of your pregnancy
3. Consider all of your options: adoption,
abortion, or keeping the child
4. If you decide to keep the child, get a physical
exam and prenatal care immediately
5. Get all the information that you can, and take
care of yourself: no substance abuse, eat well, exercise, and stay in school
for as long as you can
·
If
you decide to put the baby up for adoption:
follow all of the above steps, but make an appointment with an adoption agency
·
If
you decide to have an abortion:
follow steps # 1-3, learn the laws about abortion from your state, talk to your
doctor, and know the procedures of an abortion
Initial Signs of pregnancy
(First 3 months):
Sometimes you don't even know you are pregnant. Although some symptoms
are the same for some women, all women go through pregnancy differently.
Here are some signs to look for:
- You missed your
scheduled period or you had an unusual period
- Breast tenderness
- Possible nausea and
vomiting
- Possible hormonal
changes which might lead to emotional changes (like pms)
The stages of Pregnancy
The
growth process of a fetus into a full-grown baby is a process that undergoes
many changes that affect both the baby and the mother.
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Beginning: |
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The fertilized egg is only a group of 13-32 cells
after the third day the egg was implanted. It will soon change into an embryo
and get 40x bigger than the size of the group of the 13-32 cells. |
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9-12 weeks: |
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13-20 weeks: |
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21-25 weeks: |
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26-29 weeks: |
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30-38 weeks: |
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Maternal health
Staying
Healthy During Pregnancy
It
is very important to take care of yourself while you are pregnant because not only
are you acting for yourself; you are also acting for your baby.
To
ensure safety, you can follow these simple steps:
1. see the doctor as soon as you think you are
pregnant
o
A
doctor can give you special care when its needed and she/he will keep track of
how both of you are doing throughout the pregnancy
2. ask your doctor about exercise
o
Don't
do any strenuous exercising
o
Some
women find that exercise in the earl stages of pregnancy can alleviate future
discomfort
3. your diet is of the greatest importance when you
are pregnant
o
Your
baby must have the correct vitamins and nutrients to grow and mature healthily
o
Eat
and drink lots of vegetables and milk. You shouldn't eat low fat when you are
pregnant because your body demands for more fat
o
NO
Caffeine. If it makes you jittery, imagine what it would do to a
4. Alcohol is not one of your options, don't touch
it while you are pregnant, it's a danger to you and your child
o
Any
amount of drinking can lead to fetal alcohol syndrome which leads to
retardation and face deformities
o
Alcohol
also causes low weight and delayed growth
5. Smoking is also not an option, don't touch a
cigarette while you are pregnant because your baby will also become addicted to
Nicotine which can lead to low birth-weight and other complications
Most
importantly, use your intelligence. Don't do anything that might put your
babies’ health on the line or in danger. If you have any questions whatsoever,
asks your doctor what is best and how you might be able to find better ways to
keep yourself and you baby healthy.
Tips
for Eating
Many women think that being pregnant means you
can eat whatever you want. This is not true. What you eat affects you, your
baby, and your pregnancy.
- When you are
pregnant, you should try to eat as many fresh fruits and vegetables, whole
grains, and peas or beans as possible
- Stay away from
processed foods
- Take a
vitamin/mineral pill high in iron and calcium
- Eat foods in their
most natural state
- Eat lots of
carbohydrates
- 3/4 of your plate
should be grains, fruits, vegetables, and peas or beans
- Try to eat at least
one grain and one fruit or vegetable in every snack
- Before you eat, ask
yourself "Is this good for me and my baby?" If your answer is
yes, then eat it. If the answer is no, then don't eat it. Try to find
something that is healthy but also satisfies you.
- Fat, sugar, and salt
intake shouldn't be eliminated totally, but reduced.
Things
those are good to do during a pregnancy:
- Taking folic acid
(it protects the baby against birth defects of the spine and brain)
- Have a well a
balanced diet
- Do some exercise
- Get plenty of sleep
- See your doctor
regularly
Things to be avoided During Pregnancy:
- All substance abuse
such as Smoking, alcohol, and drug use are dangerous
- Smoking: is a cause
for birth defects
- Alcohol: is harmful
towards the growth of the baby's organs and causes fetal alcohol syndrome
- Drug use: causes
the baby to be addicted to the drug the mother used and causes the baby to
have slow brain growth. It also causes the baby to have brain damage and
prematurity or miscarriage
- Excess vitamin A
- causes an increase
of birth defects rate
- X-rays (during the
first 12 weeks of pregnancy)
- Accutane (cystic acne
medication)
- causes birth
defects such as: mental retardation, facial abnormalities, heart defects,
and hydrocephaly (enlarges the fluid filled spaces of the baby's brain)
- also causes
miscarriage
- Soft Cheeses (feta,
brie, roquefort, camembert, and Mexican style cheeses)
- cheeses listed
above may be contaminated with bacteria called Listeria causing a disease
which can kill the baby
- Raw or un-cooked foods
- make sure all the
food you eat is clean, well cooked, and keep leftovers wrapped before
putting them in the refrigerator
- Cat feces (cat poop)
- Cat feces have a
parasite called Toxoplasma gondii that carries a disease called
Toxoplasmosis.
- Toxoplasmosis causes:
·
Sight
loss infections
·
Death
·
Seizures
·
Cerebral
palsy
·
Learning
disabilities
·
Mental
retardation
·
Hydrocephalus
(increase of fluid in the brain
·
Miscarriage
·
Stillbirth
(when child is born dead)
·
Enlarged
liver and spleen
·
Pneumonia
·
Jaundice
(liver problems that cause eyes, and skin to turn yellow and urine to turn
brown)
Pregnancy crisis
centers
http://www.pregnancycenters.org/
http://www.teenshelter.org/contact.htm
http://www.teenadvice.org/help/numbers.html
http://www.flash.net/~netccpc/
http://www.ppsp.org/teens.html
http://www.episcopalian.org/noel/pregnant.htm
http://www.pregnancycounseling.org/
|
What's
contraception?
The Pill |
|
|
The pill has female
hormones estrogen and progestogen. It works by stopping ovulation. Hormone
pills are taken every day for 21 days, then a sugar or dummy pill on the
28-day pack is taken for the next 7 days or no pill for 7 days in the 21-day
pack. Not all women are able to take the pill. It is available with a
doctor's prescription only. The failure rate is less than 1% if taken as
directed. |
|
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Emergency
Contraception
|
|
More facts about
contraception
After
a woman has given birth not all forms of contraception can be used, but
pregnancy is possible as soon as the woman is sexually active again. She should
discuss the methods that are suitable for her to use with a doctor, midwife or
Family Planning.
A woman can get pregnant when:
- she has sex during her period
- she has sex for the first time
- the man ejaculates around the outside of the vagina
Condoms are the only method of contraception that will
prevent against sexually transmitted diseases (STD).
If you think your partner may have:
- an STD
- sex with other people
- taken a risk at any time
Use a condom as well as
your current method of contraception! 
Enjoy Sex Safely
Safer sex involves protecting yourself emotionally and
physically.
Have sex that lets you:
- feel good about yourself and your relationship
- avoid unintended pregnancy
- prevent sexually transmitted diseases
Feel good about yourself and the decision you make.
You decide :
- when to start having sex
- whether or not to have sex every time your partner wants you to
- to practice safer sex every time.
Communicate with your partner about:
- whether you want to have sex
- where and how you like to be touched
- what your limit is
- past and present experiences which may put you or your partner at
risk
Respect yourself and your partner:
- be honest
- consider your own and your partner's cultural beliefs and personal
values
- accept responsibility for your sexual behavior
Stay
in control
- protect against physical and/or emotional harm
- be sure to have access to protection
- be aware that drinking alcohol or using other drugs may affect your
ability to make safe decisions.
There are more than 50 known diseases that can be
passed on through intercourse. STD's can be passed from one person to another by exchange
of body fluids (blood, semen, vaginal fluids, and discharges from sores caused
by STD's).
These include:
- sexual intercourse, oral, or anal sex
- close sexual contact
- mother to baby transmission during pregnancy and/or childbirth
- injecting drugs
You are at risk of getting a STD when:
- you are starting a new relationship
- you have more than one sexual partner
- your partner has other partners
- you and your partner share sex aids such as dildoes or vibrators
- you or your partner injects drugs and share needles or the other injecting
equipment
Facts
about STD's
- you can't tell if a person has an STD by looking at them
- not all STD's have symptoms
- you can have a STD and pass it on to others without knowing it
- a STD won't go away without treatment
- most STD's can be treated or cured
- STD's can cause infertility, illness or death.
Enjoy
safer sex
- use condoms every time you have vaginal or anal sex
- use dental dam or condom during oral sex
- use only water based lubricants, never oil or petroleum based
products because they damage latex
- use condoms to cover sex aids like dildoes and vibrators
Know
that :
- early diagnosis of a STD is important to avoid serious complications
and so you don't pass it on to others
- don't wait for symptoms - get tested if you have any concerns about
having a STD
- don't be embarrassed to ask for a test- anyone can get an STD
- all info you give to health care professional
Violence: A World-wide
epidemic
Violence in all its forms has increased
dramatically worldwide in recent decades. Apart from civil conflict
and war, violence - being destructive towards another person - can be
interpersonal, self-directed, physical, sexual and mental. It is a generic term
that incorporates all types of abuse - behaviour that humiliates, degrades or
injures the well-being, dignity and worth of an individual.
Violence
crosses all boundaries, including age, race, socio-economic status, education,
religion, sexual orientation and workplace. A recent report concludes that
workplace violence has also gone global, crossing borders, work settings and
occupational groups. Violence has become a public health concern of
epidemic proportion with extensive health care ramifications. During 1993, at
least 4 million deaths (8% of the total) resulted from injury due to
aggression. Of these violent deaths, some 3 million were in the developing
world.
In
many countries, violence is endemic and the leading cause of death among males
aged 15 - 34. The burden of violence however is disproportionately borne by
young people and women. Gender violence is considered a universal plague even
though it continues to be grossly underreported.
Gender Violence
Women
are targets of violence more often than men. They are subjected to domestic and
workplace violence, manifested through physical and verbal abuse, sexual
harassment and bullying. Certain culturally condoned practices, such as female
genital mutilation and son preference, are also considered violent acts against
women. Recently, special attention has highlighted the plight of women in times
of social disorder - victims of organised rape in armed conflict situations or
sexual violence in refugee camps.
Societal
tolerance of such abuses has contributed to the existence of such behaviours.
In many societies, wife abuse is acceptable behaviour and justified as a
routine part of married life. The absence of credible support systems for women
victims helps perpetuate an escalation of violence.
Nurses and Nursing
Nurses
have a particular interest in eliminating violence. As health care
professionals, nurses often have first line contact with the increasing numbers
of the victims of violence. Regrettably, a small number of nurses have also
been known to be perpetrators of violence, patient or colleague abuse in
violation of nursing's code of conduct. Nurses also suffer from societal
tolerance of violence. The legal system has on several occasions refused to
grant compensation to nurse victims. This was justified on the principle that
to practise nursing was to accept the risk of personal violence. Nurses
themselves often feel that they are "legitimate targets" and that
violence is "part of the job".
Ninety-five
percent of nurses around the world are women. Attitudes towards women are often
reflected in interactions with the profession.
What
are some of the relevant statistics?
·
Health
care workers are more likely to be attacked at work than prison guards or
police officers.
·
Nurses
are the health care workers most at risk, with female nurses considered the
most vulnerable.
·
General
patient rooms have replaced psychiatric units at the second most frequent area
for assaults.
·
Physical
assault is almost exclusively perpetrated by patients.
·
97%
of nurse respondents to a
·
72%
of nurses don't feel safe from assault in their workplace.
·
Up
to 95% of nurses reported having been bullied at work.
·
Up
to 75% of nurses reported having been subjected to sexual harassment at work.
A
campaign for zero-tolerance of violence at the workplace needs to address the
contributing factors, namely: working in isolation, inadequate staff coverage,
lack of staff training, poor inter-relationships within the work environment
such as managers' disinterest, difficulty dealing with people who have been
drinking or taking drugs, and with people under stress, frustrated, violent or
grief-struck.
What are the statistics?
- In the
- In the developing
countries, one-third to over one-half of women report being beaten by
their partner4. In
- In the
- According to the
World Health Organization, 85 - 115 million girls in the world's
population have undergone some form of female genital mutilation and
suffer from its adverse health effects.
- In a large
- Thousands of women
held in police custody world-wide are routinely raped.
- World-wide, the vast
majority of sexual harassment victims are women.
Interpersonal
violence is a major societal problem with consequences for health and
well-being. There are approximately 250,000 Registered Nurses, 75,000
Registered Practical Nurses and 5,500 Psychiatric Nurses in
This document presents an overview
of the recent literature (1995-2000) on the education of nurses in the area of
violence prevention, detection and intervention. The goal is to inform
educators, researchers and policy makers about gaps in educational services and
areas of needed research.
On-line searches were conducted of CINAHL, Medline, Sociofile and Psychfile,
large bibliographic databases, using OVID as the search engine and key words.
Reference lists were hand searched for additional recently published articles
and for articles published before 1995 that seemed particularly important to
nursing education. Letters of inquiry were also distributed to the Centres of
Excellence for Women’s Health, the Research Centres on Family Violence and
Violence Against Women, deans and directors of university schools of nursing,
and the Canadian Association of Schools of Nursing for unpublished documents
and reports related to the education of nurses in the area of violence. A draft
report was distributed to a panel of experts in the field of violence
prevention for critical appraisal, and refinements were made as recommended.
The findings showed that the
literature on the education of nurses in the area of violence prevention,
detection and intervention is limited. Responses to letters of inquiry revealed
collaboration among researchers at the Centres of Excellence for Women’s
Health, the Research Centres on Family Violence and Violence Against Women, and
faculty members of university schools of nursing. With one exception, involving
a study conducted by students, there were no ongoing or unpublished projects
reported that related to the education of nurses.
The literature, in large
measure, focuses on
·
_ the
importance of a theoretical and conceptual basis for nursing education and
research,
·
_ the
importance of experiential learning
·
, and the
integration of concepts from a variety of disciplines.
Levels of
Education
Nursing education occurs
at many levels. There is some direction in the literature with respect to the
education of nurses and other heath care providers at different levels of
practice. Hoff (1994) provided direction for class/seminar planning. She
divided the global curriculum content required for knowledgeable and skilful
health care providers into three levels of professional education (beginning,
intermediate, and advanced). At the beginning level, the emphasis is on
description and primary prevention in personal and student-role behaviours.
Students are introduced to the topic and sensitized to the issue of violence in
a way that does not overwhelm them but conveys that they have an important role
to play in violence prevention. At the intermediate level, the emphasis is on
analysis, clinical application, and a critique of clinical performance based on
principles described in the literature. The focus is on students’ understanding
and application of assessment and intervention strategies in a variety of
clinical settings. It is assumed that not all students will encounter each type
of survivor; rather, they will learn the basic strategies through their own
research, study and other learning experiences. At the advanced level, the
emphasis is on the synthesis of concepts and the refinement of skills learned
at previous levels of education. This level assumes that students have grasped
essential concepts of crisis intervention and treatment on behalf of survivors,
and have planned opportunities to work with people in actual or potential
situations of violence.
Brandt (1997) advocated different levels of education for varying levels of
practitioners: general, nurse practitioner, specialty practice, and
consultants, investigators and educators. The author described the goals and
objectives of courses designed for different levels of practice. A core course
focuses on generalist practice and emphasizes attitude development, core
knowledge and skills development related to effective screening, diagnosis, and
referral. A second level course focuses on specialty practice and emphasizes
intensive, targeted, specialty-focused assessment and intervention with
survivors of violence. Barriers to professional practice are explored, as are
the legal aspects of care. A third level course focuses on research and
educational issues related to violence and the skills required for the
consultation role.
Abuse of human life
Abuse of human life assaults the dignity of a
person as a bearer of the image of God. Human abuse is an offense against
God. Abuse may be physical, psychological, or emotional. Furthermore,
there is a spiritual dimension to abuse. The resulting harm may be
permanent, reparable, or only partially reparable. While not all harm is the result
of abuse, abuse results in harm.
Abuse arises from pride,
greed, lust, hatred, ignorance, or indifference. Abuse may be intentional
or unintentional; it may result from inappropriate acts of commission or
omission. General conditions of human abuse may be directed against people in
many ways.
For example:
·
Persecution or genocide of people sharing a
common ethnic, political, racial or religious identity.
·
Misallocation or maldistribution of resources
causing inadequate relief, starvation, or death.
·
Human trafficking for purposes of servitude or
sexual exploitation, such as prostitution, predation, and pornography.
·
Coerced bodily mutilation, e.g. female
circumcision, dismemberment.
·
Unjust treatment of prisoners.
·
Coerced retrieval of gametes, organs, or embryos.
·
Child abuse, spousal abuse, elder abuse and other
forms of relational abuse.
Individual health care professionals engaged in
the care of a person who is in an abusive situation have substantial attendant
responsibilities in addition to providing appropriate medical care. They
should affirm the victim’s worth as a person loved by God. Insofar as
possible, they should assist in the reparation of the abusive situation, in the
removal of the individual from the situation if there is threat of imminent
harm, and in the rehabilitation of the abused individual. This almost
always will involve reporting to authorities so that the perpetrator can be
dealt with appropriately.
The International
Council of Nurses
(ICN) defines abuse as behavior that humiliates,
degrades or otherwise indicates a lack of respect for the dignity and worth of
an individual and the American Association of Critical Care Nurses (AACN)
states that abuse can take the form of intimidating behaviors such as
condescending language, impatience, angry outbursts, reluctance or refusal to
answer questions, threatening body language and physical contact. The emotional
impact of abusiveness demoralizes people and can leave the victim feeling
personally and/or professionally attacked, devalued, or humiliated.
Abusive behavior and/or abuse of authority and position can occur in any
setting where nurses practice both domestically and internationally.
The International Council of Nurses states that:
• All forms of abuse and violence against nursing
personnel, including sexual harassment, shall be condemned;
• Incidents of abuse against nursing personnel are
considered to be violations of nurses’ rights to personal dignity and
integrity;
• Abuse and violence in the health workplace threatens
the delivery of effective patient services;
• If quality care is to be provided, nursing personnel
must be ensured a safe work environment and respectful treatment; and
The American Association of Critical Care Nurses condemns acts of abuse perpetrated by or
against any person and demands a zero-tolerance stance on any abuse and
disrespect in the workplace.
The American Nurses Association established a Code of Ethics for Nurses with
Interpretive Statements which mandates that registered nurses:
• Respect the inherent worth, dignity, and human rights
of every individual;
• Maintain compassionate and caring relationships with
colleagues and others with a commitment to the fair treatment of individuals,
to integrity-preserving compromise, and to resolving conflict
• Be responsible for creating, maintaining, and
contributing to environments that support the growth of virtues and excellences
and enable nurses to fulfil their ethical obligations.
The same Code of Ethics for Nurses with Interpretive Statements mandates
that professional organizations:
• Support and assist nurses who report unethical,
incompetent, illegal, or impaired practice and to protect the practice of those
who choose to voice their concerns.
• Maintain vigilance
and take action to bring about social change and speak for nurses collectively
on issues such as violations of human rights.
The same Code of Ethics for Nurses with Interpretive Statements is not
open to negotiation and may supersede specific policies of institutions, of
employers, or of practices; therefore be it
The American Nurses Association shall adopt the following principles related to nursing practice and the
promotion of healthy work environments for all nurses:
• that all nursing personnel have the right to work in
healthy work environments free of abusive behavior such as bullying, hostility,
lateral abuse and violence, sexual harassment, intimidation, abuse of authority
and position and reprisal for speaking out against abuses; and
• that the language of The Code of Ethics for Nurses
with Interpretive Statements is nonnegotiable and the ethical precepts of the
Code encompasses all nursing activities in all settings in which nurses practice,
learn, teach, research, and lead, and may supersede specific policies of
institutions, of employers, or of practice; and
• the registered nurse should report promptly
incidents of abuse and advocate that no employee who experiences and reports workplace
abuse faces reprisal; and
• registered nurses should advocate for the
implementation of policies that support abuse free, harassment free and
violence-free workplaces through a comprehensive workplace security and
violence prevention program, and
• the registered nurse should take appropriate action
following an incident of abusive behavior to prevent recurrence of similar
incidents; and be it further,
The American Nurses Association shall condemn abuse and harassment of nurses in professional associations
and in all work environments in which nurses practice, including abuse and
harassment, based on age, color, creed, disability, gender, health status,
lifestyle, nationality, race, religion, or sexual orientation; and be it
further
The American Nurses Association, through and/or along with the constituent member associations, shall
provide guidance and support for nurses who speak out about abuses, abuse of
authority and position, and suffer reprisal for speaking out against such
abuses and promote appropriate activities that support whistle blowing
surrounding these issues.
References
1. WHO (1997) the World Health Report 1997,
2. ILO (1998) When Working Becomes Hazardous. World of Work, 26
3. UN (1996) Human Rights: Women and Violence.
4. Jejeebhoy, S.J. (1998) Implications of domestic
violence for women's reproductive health: what we know and what we need to
know. Biennial Report 1996-1997.
5. UN (1996) Human Rights: Women and Violence.
6. Contact (1993) Why Women's Health? No 131, p3.
7. UN (1996) Human Rights: Women and Violence.
8. UN (1996) Human Rights: Women and Violence.
9. ICN (1994) Coping with Violence in the
Workplace
American Association of
Colleges of Nursing. Position Paper: Violence as a Public Health Problem.
Atwood, M. The
Handmaid’s Tale.
Beech, B. “Sign of the
times or the shape of things to come? A 3 day unit of instruction on aggression
and violence in health settings for all students during pre-registration nurse
training”, Nurse Education Today, 19, 8 (1999): 610-16.
Benner, P. From Novice
to Expert.
Bishop, J, B. Lent. Woman
Abuse Case for Problem Based Learning.
Brandt, E.N. Jr.
“Curricular principles for health professions education about family violence,”
Academic Medicine, 72, 1 Suppl (1997): S51-58.
Brendtro, M. and H.I.
Bowker. “Battered women: How can nurses help?” Issues in Mental Health
Nursing, 10 (1989): 169-80.
Brown, L. “Workplace
violence: experiences of nursing home workers,” Journal of the Ontario
Occupational Health Nurses Association, 18, 2 (1998): 4-10.
Burkell, J. and K. Ellis.
Principles of Effective Anti-Violence Education: A Review of Prevention
Literature.
Byrne, C.
“Interdisciplinary education in undergraduate health sciences,” Pedagogue
Program for Educational Development, 3, 3 (1991): 1, 3-8.
Calvert, W.J. “The
effects of violence in society upon nursing curriculum imperatives,” ABNF
Journal, 7, 5 (1996): 124-28.
Canadian Nurses
Association. Family Violence: Clinical Guidelines for Nurses.
Canadian Nurses
Association. Policy Statement on Violence in the Workplace.
Canadian Panel on
Violence Against Women. Final Report of the Canadian Panel on Violence
Against Women: Changing the Landscape: Ending Violence Achieving Equality.
Supply and Services