Final Year Nursing Students’ Attitudes Toward Violence Against Women: A Pilot Study in Tallinn Health Care College, Estonia

Aim: The aim of this study was to research final year nursing students’ attitudes toward violence against women. Background: The topic has not been studied before in the context of Estonian higher education colleges of health care, and the attitudes of nursing students towards violence against women (VAW) are not known, so there is no effective input for changing the content quality of the curriculum. Methods: Cross-sectional survey design was used. Results: The pilot study found that many respondents had personal experience with various types of violence. Over 90% of final year nursing students disagree with the negative myths and stereotypes prevalent in society regarding VAW. 90.8% of the respondents consider that VAW issues are not dealt with sufficiently in Estonian society and 47% of the respondents found that they do not know how to properly provide help to victims of violence, as they lack knowledge, skills, and experience. It was also noted that future nurses, would need more training on violence in order to provide professional help. The research subjects indicated that there could be a specific subject in curriculum that deals with different types of violence, identifying the victim, intervention and providing professional nursing care, and network cooperation. Conclusions: The present pilot study raises the need to research nursing students’ attitudes toward VAW with a larger sample and with a better designed questionnaire. Necessary to develop subject of violence should be included in the nursing curricula by integrating it into existing courses. Implications for nursing: Raising health students’ awareness and skills about violence will help to provide the best possible support and assistance to victims of violence.


Background
The United Nations defines violence against women (VAW) as any type of gender-based violence that causes or is likely to cause physical, sexual, or mental harm or suffering to women, including threats of acts, coercion, or arbitrary deprivation of liberty in both public and private life [1,2].VAW is internationally described as a serious global public health problem with severe consequences, not only for the woman herself, but also for her children.Besides individual suffering, VAW.[3].Therefore, to deal with violence against women, a functioning healthcare system is needed to prevent or intervene in the problem [4].According to the European Union's Equality Commissioner, victims of VAW across Europe need more effective protection, as one in three women in the European Union has had to endure mental, physical, or sexual violence.More than 50% of women have experienced sexual harassment after the age of 15 [5].Even though the Estonian population (50-61%) considers VAW to be quite a serious problem, the attitude of blaming women as victims prevails, where every third Estonian (41% of men and 19% of women) believes that the problem is exaggerated [6].54% of Estonian women have fallen victim to physical violence at home.Since violence has a very large impact on health, in addition to physical trauma, it also causes mental health problems, which in turn can exclude a person from social life or instead cause incapacity for work [7].
Unfortunately, health services are often inadequate in responding to violence, even though most victims of violence use health services.And even when patients speak of their own victimization and suffering, there is evidence that health professionals often lack the skills and experience to respond appropriately [8].A survey was conducted among Estonian healthcare workers in 2014, which revealed that among healthcare workers, the attitude of blaming the victim prevails, where 28%-79% believe that the woman herself provokes VAW with her behaviour.91%-94% of the respondents mention time as an obstacle to helping the victim lack, and 86%-97% of the respondents point to the lack of special preparation as the main lack [9].Health care workers, nurses and midwives are in a unique position to identify and help victims of VAW, since they are often their first point of contact in the healthcare system [10][11][12][13][14][15].The ability of nursing staff and nursing students to help the victim and to recognize the signs of violence is influenced by their attitudes [16][17][18].It has been observed that if a health worker has been exposed to violence him or herself, his knowledge and response skills are better [8].Nursing students may be aware of the importance of violence education, but their level of knowledge is not sufficient, and they must be thoroughly trained [12,13,19].It has been noticed that future health care providers not received adequate training, either before or after graduation, to recognize incidents of violence and to deal with VAW [20].In the context of Estonian society and health care, this topic is relevant, as it can be seen from the above that VAW is a serious problem.The common misconception among healthcare professionals that women as victims are to blame for provoking violence was also highlighted.Since healthcare workers meet victims of violence in their work, they must have the capacity notice violence, intervene, and provide help within their competence.So far, the attitudes of nursing students as future healthcare workers towards VAW have not been studied in Estonia.

Aim
The aim of this pilot study was to research final year nursing students' attitudes toward VAW.The one goal was to find out if final-year nursing students have personal encounters with VAW.The main goal was to find out the final year nursing students' attitudes toward VAW and to test the functioning of the questionnaire in a pilot study.

Study design
The method of the study is a cross-sectional survey.The research target group is the final year nursing students at Tallinn Health Care College.Final-year students were selected for the pilot study because their attitudes cannot be changed during study, but the insight and results obtained from them allow shaping the attitudes of nursing students who are still studying.

Participants and settings
Final year nursing students received an invitation to participate and a link to the questionnaire by e-mail.The cover letter explained the purpose of the research, the voluntariness of participation in the study and the approximate time required for answering.200 final year nursing students were invited to participate in the study.Data were collected in the period 2020-2021.The survey was answered by 73 nursing students, or 36% of all respondents.Statistically, the responses obtained from 36% of the subjects are not reliable for generalization, but the results obtained can be analysed to provide initial insight into the pilot study, highlighting the limitations and strengths of the pilot study.Due to the pilot study, no other background data were collected (relationship status, etc.).

The questionnaire consists of 31 questions and is structured into three blocks:
The first block of the questionnaire contains questions asking about nursing students' personal contact with different types of violence (mental/verbal; physical, including sexual and economic violence).Each question is followed by answer variants and the subject can choose several suitable variants.
The second block contains socio-cultural issues that occur in the Estonian cultural space and are so-called statement issues [9] Socio-cultural questions are prepared on the principle of a Likert Scale.
The third block contains questions about Estonian legislation, the possibilities, interventions, and necessity of helping victims, as well as the readiness of final year nursing students to help a victim of violence especially women.
There is also the option of adding a comment at the end of each question to justify, expand or give your own explanation and meaning to your answer.

Results
The participants in this study have personal experiences with different types of violence (Table 1).Respondents admitted that they had experienced mental VAW.13.1% of them have come across feelings of guilt, 12.9% by mocking and humiliating, 11.9% by scolding, nagging, 11.9% by verbally attacking or threatening.The least encountered (6.1%) is making comments about mental abilities.

Examples of comments: "I myself have both witnessed and personally experienced being called offensive nicknames and comments about my appearance. It has left a strong mark on my self-esteem." "My father constantly accused me of something, no matter what. I lived in an atmosphere of constant accusation and fear." "My previous husband often terrorized me, threatened me, called me stupid and a problem person with learning difficulties which affected my ability to cope." "My parents have accused me from school to adulthood and these accusations still have an impact."
Respondents have experienced physical, including sexual, VAW in the following environments: 22% at a party, 12.1% in a public urban space, 11% on thresholds with male relatives and/or acquaintances, 10.4% in their previous marriage or relationship, 6.9% in their family of origin (in the parental home), 5.2% in a work environment, 2,3% in a study environment and 1.2% in their current marriage or relationship.

Examples of comments:
"The fact that someone puts their hands on you and harasses you at parties is still a spreading trend in my opinion.As if, according to some young men, the girls at the party went there for that.I have experienced and witnessed this many times myself"."I have experienced walking in the city, where a strange man just passes by and touches my body".
"When I was a little girl, my father's friend groped me in the intimate area ... I still remember it with horror.""As a small child, I experienced violence when my father beat my mother and my sisters, and I locked ourselves in a room.My father also threw ether in my mother's face and was violent, the police intervened in this situation"."Drinking alcohol, the partner became violent every time.In front of the child, he constantly hit me, threw me, dragged me.Threw my clothes out of the window... Threatened to make my life hell ".
The respondents have experienced economic VAW in the following environments: 21% in the family of origin, 22% in the current relationship or family.

Examples of comments:
"My parents financially supported my brothers, but not me, because I was a girl, and my education was not important for them.""My ex-husband doesn't pay us child support.""My ex-boyfriend insisted that we pay all expenses equally and in reality, I still paid everything.""It is difficult for me to cope financially, study and work when my finances are constantly being checked."The results of the second, or socio-cultural, block are as follows: With the statements "He who hits, he loves", "If a woman nags, a man can hit", "The woman herself is to blame or causes the situation that the man knows to hit", all the respondents answered that they do not agree with it or do not agree at all.5.7% of the respondents responded that they rather agree with the statement "Being hit once is not yet violence" and 94.3% do not agree or do not agree at all.With the statement "Wearing a short skirt and/or a wide neckline is one of the causes of sexual violence", 12.7% rather agreed with the statement, and 87.3% disagreed or did not agree at all.5.9% of the respondents rather agreed with the statement "A woman's flirtatious behaviour means consent to sexual intercourse", and 94.1% disagreed or did not agree at all.92.5% of the subjects fully or rather agreed with the statement "If during sexual intercourse a woman wants to interrupt (abstain) the act and the man refuses, it is rape", and 7.5% disagreed or did not agree at all.1.4% of the respondents fully agreed with the statement "A woman can be physically called to order if necessary", and 98.6% do not agree or do not agree at all.3.3% of the respondents rather agreed with the statement "Educated men are not violent", and 96.7% did not agree or did not agree at all.With the statement "Less educated or men with a lower level of education are more violent", 24.6% of the survey respondents rather agreed with the statement, and 75.4% did not agree or did not agree at all.4.3% rather agreed with the statement "A woman's place is mainly at home" and 95.7% disagreed or did not agree at all.
To the questions of the third block, whether the topic of VAW is dealt with sufficiently in Estonian society, 90.8% of the survey respondents answered that rather or completely insufficiently.9.2% of the respondents found that they are being dealt with completely or rather sufficiently.98% of the respondents agree with the statement that any kind of violence, especially VAW, is unacceptable.47% of the respondents found that they do not know how to properly provide help to victims of violence, as they lack knowledge, skills, and experience.
The respondents of the study found that more attention should be paid to the existence of VAW in Estonia.It was found that the legislation does not support the woman as a victim, therefore, 80% of the respondents are of the opinion that the legislation should be supplemented.Assistance to victims should be more effective and accessible.It was also noted that healthcare workers, including future nurses, would need more training on violence in order to provide professional help.The research subjects indicated that there could be a specific subject in curriculum that deals with different types of violence, identifying the victim, intervention and providing professional nursing care, and network cooperation.

Discussion
VAW is a significant problem in both Estonia and around the world.In Estonia, the attitudes of nursing students toward VAW have not been studied before it is a pilot study.Many studies have contributed to the study of VAW in the last ten years, but the attitude of nursing students towards VAW has been studied less.The present study demonstrated that 98% of the respondents agree with the statement that any kind of violence, especially VAW, is unacceptable which shows that attitudes towards VAW are negative.
13.1%-11.9% of the respondents have encountered the most common manifestations of mental violence (causing guilt, mocking, and humiliating, scolding, nagging).22%-1.2% of the respondents have experienced physical, including sexual violence, and 21%-22% of the respondents have experienced economic violence.In the comments of this study, the respondents emphasized that verbal abuse has left the biggest mark on their self-esteem and affected their coping skills.Mental violence was described in the comments as a continuous and ruinous phenomenon, the effects of which are felt for a long time and the consequences of which are more severe.Similar studies in Turkey found that students studying in the health curriculum had experienced mental VAW that had affected them.Mental violence was mostly experienced by a male family member or loved one [16,21,20].Simsek & Ardahan's survey of senior year nursing and midwifery students reveals that 24.6% of students have suffered from mental violence.The authors of current study are of the opinion that experienced mental violence is a serious problem and can affect an individual's ability to cope for a long time.Mental violence seen or experienced personally, either in childhood or later in life, affects various aspects of an individual's life [22].
When experiencing physical, including sexual, violence, several respondents mentioned that they felt "as if they were to blame or responsible for what happened."According to the authors of the study, sexual violence is a particularly vulnerable form of violence for the victim, which is at the same time the worst more controversial.Sexual violence can easily be seen as an individual problem for the victim.The result of the Kase & Pettai [9] survey reveals that according to Estonian healthcare workers (77%-79%), women in Estonia behave thoughtlessly, causing undesirable consequences.In terms of sexual violence, there is no clarity on where the line between violence and voluntary action is and whether there is anything to condemn in the victim's actions.
Women are therefore particularly vulnerable and deeply hurt received.During the investigation, they are often asked about their role in the incident were you there voluntarily, how did you Volume 06; Issue 09 Int J Nurs Health Care Res, an open access journal ISSN: 2688-9501 dress, why did you go there alone, etc [23].Physical violence was experienced less than sexual violence in this study, which does not mean that it does not occur.Because there was no reliable sample, the authors of this study cannot draw general conclusions.A study by Pettai [6] conducted in Estonia pointed out that the topic of VAW is overemphasized in society, but the actual situation reflects that 54% of women have experienced physical violence [7].Also in the current study, students mentioned a personal experience with physical violence.Pereira et al. [24] emphasizes that any VAW affects a women's ability to cope, self-esteem and is a serious threat to mental and physical health.
Economics is not the first association that comes to mind when thinking or talking about VAW [25].Respondents' experiences with economic violence are indicated both in the family of origin and in the current relationship or family (21%-22%).The FRA survey sees economic violence as part of psychological violence, but separates it out, matching the concept with the following behaviour on the part of the respondent's partner: "Preventing the respondent from making decisions on family finance or shopping independently, or forbidding her to work outside the home" [26].An Economic violence against women suppresses a woman's selfesteem, decision-making ability, access to both education and the labour market [27].Although the prevalence of economic violence among students is estimated to be low, even lower than that of working women, it has a psychological impact and a negative consequence [25].Based on Hegarty et al. [8] study, it can be confirmed that more than 20 scientific studies show that a health worker's personal experience of violence has a greater impact on the victim's commitment, understanding and willingness to help.
In the block of socio-cultural characteristics of the current study, social myths and negative stereotypes related to VAW prevalent in Estonian society were investigated.Over 90% of final year nursing students do not agree or do not agree at all with the negative myths and stereotypes prevalent in society regarding VAW.According to the authors of the research, this is a positive result, as a negative attitude towards stereotypes in society is an effective potential for helping and supporting the victim of violence.The literature has largely shown that myths of violence are strongly linked to the support of gender stereotypes and ambivalent sexist attitudes that contribute to the prevalence and perpetuation of VAW (Di Giacomo et al, 2017;Herrero et al., 2017;Lelaurain et al., 2019)., Social myths, and negative stereotypes about abused women encourage the justification of violence.(Di Giacomo et al., 2017).
The participants of the study found that more attention should be paid to the existence of VAW in Estonia.80% of the respondents are of the opinion that the legislation should be supplemented.47% of the final year nursing students found that they do not know how to properly provide help to victims of violence, as they lack knowledge, skills, and experience, which is an unfortunate factor.Simsek & Ardahan [20] study found that final year nursing and midwifery students recognize the signs of VAW, but they have lacked the skills to help the victims.Several authors also consider that lack of knowledge was identified as an important factor, recognized as the most important barrier to care, inquiry, and diagnosis of VAW by healthcare professionals [30,31,13,32].The authors of current study are of the opinion that topics related to violence need to be addressed in health care curricula from the first year of study until the end of the study period, giving students both knowledge and practical skills to provide the best possible help to the victim.The authors Doran &Hutchinson [12,15,19] are on the same opinion, who consider that undergraduate courses are the ideal means to change nursing attitudes toward VAW, as undergraduate courses can equip students with a comprehensive understanding of VAW.Undergraduate nursing education must continually stress the relationship between exposure to violence and poor health; this will allow students to recognize exposure to violence and respond appropriately when they are treating patients in clinical settings in the future.There is strong evidence that violence training increases confidence and skills in aiding a victim of violence in a clinical setting [33,34].
The authors of this study emphasize that in order to change attitudes, provide broad-based knowledge and gain practical experience, it is necessary to introduce qualitative changes in the nursing curriculum in order to ensure the best possible help for victims of violence.Evidence-based theory learning, simulations, workshops, etc. could be suitable methods.Therefore, the subject of violence should be included in the curricula by integrating it into existing courses or including it as a separate course in each academic year [19,35,36,37].Pinar&Pinar [18] emphasizes a similar approach in improving the content quality of the nursing curriculum.The nursing curriculum should be designed to help students develop the attitudes, knowledge, and skills necessary to respond appropriately using effective learning strategies such as lectures, seminars, interactive simulation methods, workshops, peer training, and role-playing.Health educators should be strongly encouraged to find further collaborative activities for nursing students to gain hands-on experience in addressing VAW.

Limitations of the study
The pilot study has several limitations that reduced the generalizability of the findings.The limitation can be the small number of subjects (36%), which is not a statistically reliable result for generalizing conclusions but allows to analyse the attitudes of the participants in the study.The small number of subjects could be due to several circumstances.One reason could be the period of COVID-19 when many nursing students worked in the hospital's COVID units.Another possible reason can be the fact that the focus of the final year nursing students was on writing the diploma Volume 06; Issue 09 Int J Nurs Health Care Res, an open access journal ISSN: 2688-9501 thesis and it can be assumed that the subjects were mentally tired and overworked.The limitations arising from the questionnaire should be noted as an important limitation.Some of the questions were either misunderstood or were not formulated in the best way, which resulted from the peculiarity of the Estonian language.The wording of the questions needs to be corrected, reformulated, and made clearer in order to avoid multiple interpretations (especially in the first block).It can also be pointed out as a shortcoming that the questionnaire did not include questions about health risks caused by violence.The bottlenecks revealed in the same pilot study allow for the improvement of the subsequent planned similar study.As a strength, it is worth noting the in-depth comments of the respondents, which made it possible to provide a first insight into the researched topic.

Conclusion and Recommendations
The present pilot study raises the need to research nursing students' attitudes toward VAW with a larger sample and with a better designed questionnaire.Final year nursing students have personally encountered mental, physical, including sexual and economic violence.The respondents indicated that mental violence is the most negative consequence.The participants of the study found that more attention should be paid to the existence of VAW in Estonia and the respondents are of the opinion that the legislation should be supplemented.Approximately half of the final year nursing students found that they do not know how to properly provide help to victims of violence, as they lack knowledge, skills, and experience.Therefore, it is necessary to develop subject of violence should be included in the nursing curricula by integrating it into existing courses or including it as a separate course in each academic year.Raising health students' awareness and skills about violence will help to provide the best possible support and assistance to victims of violence.
Implications for nursing: Raising health students' awareness and skills about violence will help to provide the best possible support and assistance to victims of violence.
Volume 06; Issue 09 Int J Nurs Health Care Res, an open access journal ISSN: 2688-9501

Table 1 :
Experiences of respondents with different types of violence.
Volume 06; Issue 09 Int J Nurs Health Care Res, an open access journal ISSN: 2688-9501