PHYSICAL, SEXUAL AND PSYCHOLOGICAL VIOLENCE ACCORDING TO RODGERS’ EVOLUTIONARY CONCEPTUAL ANALYSIS

Objective: to clarify the concepts of physical, psychological, and sexual violence and, from the results obtained, to compare similarities and differences among concepts, their characteristics, conditions for events, and possible outcomes. Methods: Rodgers’ evolving concept analysis was used. The antecedents, attributes and consequents were extracted from 91 documents published in 2018, in Portuguese, English, French or Spanish, by search using the descriptors “physical violence”, “psychological violence” and “sexual violence”. Results: for “physical violence” 17 attributes, one antecedent and seven consequents were extracted; for “sexual violence” 31 attributes, 10 antecedents and two consequents; and for “psychological violence” 33 attributes, four antecedents and six consequents. Final considerations: different types of violence have different acts that characterize them, and that when (re)known by the nurse, allow for an optimized and quality care planning.


INTRODUCTION
Physical, sexual and psychological violence according to Rodgers' evolutionary conceptual analysis Bonamigo VG, Torres FBG, Lourenço RG, Cubas MR Terms with well-defined concepts are essential to the organization of a terminology.The International Classification for Nursing Practice (ICNP ® ) is an enumerative and combinatorial terminology developed in a Web Ontology Language (OWL).It is recognized as an information technology for allowing the collection, naming and documentation of the structuring elements of nursing practice -nursing diagnoses, outcomes, and interventions (1) In ICNP ® , each concept (Preferred Term) is represented by a defined term, hierarchically arranged, having a "parent concept" (General Term) and sometimes a "child concept" (Specific Term).The higher up in the hierarchy, the more general the term, the lower down, the more specific.For example, the concept (Preferred Term): "Violence", whose parent concept (General Term) is "Aggressive Behavior", and the child concepts (Specific Terms): "Abuse"; "Behavior, Violent"; "State of War"; "Infanticide"; "Mutilation"; and "Risk of Violence".
The ICNP ® definition of the term "Violence" is like the definition offered by the World Health Organization (WHO), understood as acts in which power or physical force is intentionally used against oneself, another person, group, or community, resulting in injury, psychological harm, death, developmental impairment or deprivation (2) .This concept, although comprehensive and applicable, does not specify crucial characteristics for multidisciplinary assistance to the person in situation of violence: the context and typology of violence suffered.
Although this gap is not identified only in the nursing field, it is necessary to consider that the ICNP ® , as a soft technology, helps the application of the nursing process in assisting people in situations of violence (3) .Therefore, it is appropriate to clarify the concepts of the different types of violence, to improve their identification and recording.Added to this relevance is the fact that, as of the second semester of 2021, the ICNP ® is part of the catalog of the Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT International).SNOMED-CT works with clear, combinable, and specific concepts, and has the policy of not including vague or very broad terms in its catalog (4)(5) .It is understood that the concept of violence contained in the ICNP ® , due to its amplitude, is inadequate to the SNOMED-CT proposal, which justifies the proposal presented in this article, the result of which will offer subsidies for future inclusion of specific terms in the terminology.
For the scope of this research, typologies of violence that express forms of violence were selected, these being: physical violence, psychological violence, and sexual violence, to conduct concept analysis.The concept analysis process refers to the process of elucidating the meaning of a concept to unify its use in each context (6) .Concept analysis differs from systematic and integrative reviews in that it produces a critical evaluation from its first methodological step (7) .For this study, Rodgers' evolutionary method was used (8) .The guiding question was: what are the similarities and differences between the attributes, consequences, and antecedents between physical, psychological, and sexual violence?
The objectives were to clarify the concepts of physical, psychological, and sexual violence; and to identify similarities and differences between the concepts, their characteristics, conditions for events, and possible outcomes.

METHOD
The Evolutionary Method of Conceptual Analysis, proposed by Rodgers, considers the cyclical movement of concept formation as an agent of knowledge maintenance, and is most often used to study and assist in the concept formation of phenomena that are constantly changing, such as terms related to violence.It is organized in five steps: Cogitare Enferm.2022, v27:e86833 Physical, sexual and psychological violence according to Rodgers' evolutionary conceptual analysis Bonamigo VG, Torres FBG, Lourenço RG, Cubas MR identification of the concept of interest and the objective of the analysis; choice of the means for data collection; data collection and organization; identification of attributes, antecedents, and consequents; making of the model case (8)(9) .Rodgers' method is essentially qualitative and differs from a literature review in that the core of the method is in the extraction of attributes, antecedents and consequents, and the literature search -the means of which are determined according to the guiding question, is only one stage of the study (8) .In this article, we present three different conceptual analyses conducted from the steps described as follows are presented.
Identifying the concept of interest and the purpose of the analysis Three concepts of interest were identified: physical violence, psychological violence, and sexual violence, with the goal of comparing similarities and differences among attributes, antecedents, and consequences of these concepts of interest.

Choosing the medium for data collection
Data collection in a concept analysis is the collection of definitions of the concepts of interest, which can be done in various media, such as scientific articles, theses, dissertations, and focus groups.Considering the objective of the present study, the medium adopted for the concept analyses was scientific articles from all fields of knowledge, not limited to the health field.

Data collection and organization
We opted for a single data collection strategy for the three concepts of interest; however, to avoid bias in data comparison and contribute to data organization, we defined those searches would be conducted individually.We used the journals portal of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes) ("Coordination for the Improvement of Higher Education Personnel (Capes"), an online library of over 130 databases, including MEDLINE, Scopus, and Web of Science.
For the search for the concept of interest "physical violence", the structured descriptor "physical violence" was used, for "psychological violence" the descriptor "psychological violence" was used, and for the concept of interest "sexual violence", the descriptor "sexual violence" was used.The terms "sexual violence" and "physical violence" are entry terms from Medical Subject Headings (MeSH), however, the term "psychological violence" has no representative in MeSH or DECs (Descriptors in Health Sciences), which made it impossible to use the refiners made available by the platform.For the descriptor of interest "sexual violence" the refiners "sexual violence" and "sexual abuse" were used, while for the descriptor "physical violence" the refiners "aggression" and "victimization" were used.For the term "psychological violence" no refiners were used.
In each of the three searches, conducted in December 2018, articles were retrieved in Portuguese, English, French, or Spanish, published in peer-reviewed journals in the same year as the search.The temporality was established due to the large number of publications related to the topic and the fact that the definitions used in the material do not necessarily reflect the temporality of its publication, as references from previous years are used.Among the retrieved articles, the full text was read and articles with explicit definition of the term of interest were included.Duplicate articles were excluded using the Mendeley ® reference manager; and articles with mixed definitions that would make it impossible to compare the three concepts of interest.To minimize selection bias, two reviewers independently read the titles and abstracts of the articles and compared the results.Disagreements were resolved by consensus.A third reviewer was present for full-text reading and analysis.
From the articles included, the definitions identified in the literature were extracted, making it possible to extract more than one definition from a single article.The results of this process were organized in an electronic spreadsheet, with each row representing a Physical, sexual and psychological violence according to Rodgers' evolutionary conceptual analysis Bonamigo VG, Torres FBG, Lourenço RG, Cubas MR definition, complemented by columns indicating the identification code of the definition, names of the authors of the originating article, source of the definition, page of the article where the concept was found, and the Digital Object Identifier (DOI) for accessing the article.

Identification of attributes, antecedents, and consequences
The same strategy was used for the three analyses (Figure 1).From the extracted definitions, the terms (words) referring to attributes, antecedents, and consequents of the concepts of interest were identified and described in an original way to those presented by the authors of the articles.Rodgers (8) defines that the attribute of a definition is its main characteristic, while the antecedents delimit the conditions for its occurrence and the consequents delimit the outcomes.It is important to note that not all definitions of a concept of interest present attributes, antecedents, and consequents, whereas a single definition is not able to express all the characteristics, conditions, and outcomes of a phenomenon, unless it is an operational definition established from a conceptual analysis study.The antecedents, attributes and consequents extracted from the definitions are grouped to express how the concept of interest is represented in the literature and organize the model case.To avoid researcher bias, the first author performed the extraction and last author confirmed the extracted terms, in case of disagreement, the decision was made by consensus.

Making the model cases
The model case aims to illustrate a situation in which all attributes, antecedents, and  consequences are present, to facilitate the understanding of the phenomenon.The model cases built in this article are not based on real stories; however, the situations were based on characterizations described in the Atlas of Violence (10) to add veracity and to adapt the concepts to the Brazilian scenario.
To facilitate understanding and possible comparisons between the concepts of interest, the results of the three analyses will be presented together, according to the step of the method.According to the resolution in force, the evaluation in the Research Ethics Committee is not necessary for research that exclusively uses open access material, so this evaluation was waived for this research.
The flow chart in Figure 2 demonstrates the results obtained during the data collection stage.Regarding the time frame, considering the references informed by the authors of the articles from which the definitions were taken and those of their own authorship, the concept of "physical violence" presented definitions constructed between 1996 and 2018, "sexual violence" definitions constructed between 2000 and 2018 and "psychological violence" between 1999 and 2018.
Regarding the area of knowledge, the articles retrieved for the concept of interest "physical violence" are three (16.66%)from the humanities and 15 (83.33%) from the health area; the articles retrieved for the concept of interest "sexual violence" are seven (13.46%) from the humanities and 47 (86.53%) from the health area; the articles retrieved for the concept of interest "psychological violence" are six (28.57%) from the humanities and 15 (71.42%) from the health area.
To compare the concepts of physical violence, sexual violence, and psychological violence, the results have been organized into four sections: attributes, antecedents, consequents, and model case.Each section addresses the three concepts.

Attributes
The terms identified as attributes, per concept of interest, were arranged in Chart 1.
Chart 1 -Attributed terms identified in the definitions, by concept of interest.Curitiba, PR, Brazil, 2021 Any form of physical violence; corporal punishment in which physical force is used; slapping; punching; shooting; kicking; hitting; cutting; pushing; attempting to strangle or burn; threatening or attacking with a knife, revolver, or other weapon; pulling hair; hitting against something; intentionally using physical force or power against oneself, another person, or against a group or community; using force as a way to threaten, suppress, intimidate, or punish someone; associated with injury; to frighten.

Sexual Violence (n=31)
Sexual harassment; sexual humiliation; verbal and nonverbal behaviors of a sexual nature that reflect hostile and degrading attitudes; unwanted sexual behavior; unwanted sexual contact; sexual coercion; encouragement of unwanted or illicit sexual activity; physical means of obtaining sexual contact from an individual; the use of force; coercion abuse of authority or induced incapacitation by licit or illicit substances to obtain unwanted sexual behavior; sexual act committed or attempted without the free consent given by the victim; nonconsensual attempt at vaginal, oral, or anal penetration; unwanted exposure to sexual experiences; rape and molestation; forced prostitution; forced pregnancy; sterilization; stalking; intimate partner violence; unwanted sexual innuendo; actions to sell any form of sexuality anywhere; human trafficking; antisocial behavior; physical contact for sexual assault; strategy used during armed conflict, especially with regard to recruiting combatants; contested social construct; normative within our broader society; cultural; threatening, pressuring, or soliciting for sex; engaging a child in sexual activity that the child does not fully understand, is unable to give informed consent to, or for which the child is not prepared or developed; forcing a person to engage in sexual acts when that person finds it humiliating or degrading.

Psychological violence (n=33)
Insulting; threatening; attacking; verbal abuse; emotional abuse; harassment; communication abuse; causing fear; shouting; humiliating; making one feel inadequate; endangering one's self; belittling; making one feel bad; frightening and intimidating; psychological mistreatment; mental or emotional abuse; neglecting; controlling behavior; hurting women or those they care about; lack of care and attention; swearing; belittling; belittling; defaming; lack of recognition; ridiculing; mocking; gossiping about; excluding from group; restricting the victim from employment, restricting the victim from education or medical care; destroying property; insulting or frightening children; avoiding peer group; any behavior that affects the child's wellbeing or integrity.n = number of attributes Source: Authors (2021).
Regarding physical violence, the definitions presented in the articles were grouped into two main themes: (i) examples of physical violent acts; (ii) association of use of force and bodily injury.The attributes identified were punching, kicking, and hitting (11)(12) , the concept always being used as physical violence perpetrated against another person.In turn, the attributes related to intentional use of physical force are linked to the possibility of physical violence against other people and against oneself (13)(14) .
For the concept of interest "sexual violence", 34 terms were identified, most being examples of sexual acts that fall under violence.Noteworthy are the terms "stalking" (15) , "contested social construct" (16) , "normative within our broader society" (17) , and "cultural" (17) , which do not follow a pattern.
A total of 33 attributes were identified for the concept "psychological violence", which follow a pattern of similarity with examples of violent acts.

Antecedents
The antecedents of the three concepts of interest proved to be contrasting.The only term found for "physical violence" was the intention to hurt, whereas the attribute terms of "sexual violence" were hegemonically related to different prejudices and those of "psychological violence" were related to intimate relationships.

Consequents
The terms identified as consequences, for the three concepts of interest, refer to damage to physical and psychological health (Chart 3).

Sexual violence (n=2)
A global health and human rights issue, which can have short-and long-term detrimental effects on the health and well-being of the survivor; serious consequences for health and school performance.

Physical Violence
Fabrício, 56 years old, homeless for almost eight months, slept in front of a store whose owner told him to leave the place, scaring him and threatening to hurt him.Fabrício refused to leave, and the shopkeeper used violence: slaps, punches, kicks and pushes.Fabrício tried to defend himself, so the shopkeeper tried to strangle him, but he dodged.Then the store owner took a knife from his backpack and, while swearing at the homeless man, stabbed him in the chest.Local police officers were called by neighbors and stopped the fight.Fabrício was taken to the public hospital, still conscious, reporting physical pain and psychological distress.In his evaluation, a lung perforation was found.Fabrício underwent surgery and lost his life during the procedure, 12 hours after the aggression.

Sexual Violence
In a nightclub, Luís approached Maria, a young indigenous woman studying medicine in Curitiba, Paraná.She did not want physical contact with Luís, who returned to his friends and said that he was "going to have sex with an 'Indian'.Again, Luís approached Maria and offered her a drink, in which he mixed gamma-hydroxybutyric acid, popularly known as "good night, Cinderella".She, slightly apprehensive, accepted and was unconscious some time later.Luís said sexual, sexist, classicist, and xenophobic words, took her to his car, and forced sexual intercourse with Mary unconscious.Later, Luis confessed that he left her in the car, returned to the party, said goodbye to his friends, and returned to the car, telling Maria that she would be "his toy that night.In the car, he raped her again and threatened to bring more men to rape her if she refused to do as he said.She followed his orders until the police found them and Luis was arrested.Maria was treated in the hospital and later diagnosed with gonorrhea.Two months later she found out that she was pregnant, and during her pregnancy she had cardiovascular complications and diabetes.She is undergoing psychotherapy and had to interrupt college to treat anxiety, depression, and substance abuse.After the event, her quality of life, health, and academic performance dropped, but because this is a global concern, Maria found support groups for victims of sexual abuse.

Psychological Violence
Marta, 45, is a housewife who has been married for 23 years.She reports that her relationship with her husband, Joshua, is stressful because he "has a strong temper.Marta says that she is responsible for all the housework and for dinner, which must be ready by 7:30 pm, the time he gets home from work.If her husband arrives and dinner is not served, he insults her, calling her lazy and sloppy, questioning where she has been, and making her justify why the meal is late.He also rails at his grown children, saying that "his family is a disgrace, and he shouldn't have to keep working to pay for the health insurance of the profiteers.Joshua says that since he is the one who pays the household bills, Martha has an obligation to take care of the house or else he will take "measures.Martha doesn't specify what measures, but says she is afraid of them.At these times, Joshua throws objects at the walls and doesn't speak to the family for at least a day.She says that to avoid all this DISCUSSION Cogitare Enferm.2022, v27:e86833 Physical, sexual and psychological violence according to Rodgers' evolutionary conceptual analysis Bonamigo VG, Torres FBG, Lourenço RG, Cubas MR she always makes dinner at the appointed time, even when she is tired or sick, and doesn't schedule activities in the late afternoon and early evening, for fear of what Joshua might do.She feels ashamed and afraid that her children might think she is neglectful of the family, feels psychologically shaken, and has developed depression.Martha says that her daughter has already told her that she can report him, but she cannot prove what happens.
The concepts of interest analyzed in this article have different characteristics, however, all are described as categories referring to the natures of violence (18) and are related to power inequality in the relationships established between men and women, although only attributes of the conceptual analysis of sexual violence directly mention such issue.
The WHO definition meets the conceptual analysis of physical violence, although antecedents related to the contextualization of the violent act were not identified.The antecedent of "intention to hurt" (19) makes explicit the need for the intention of the act, described by WHO (2) .The absence of this antecedent in the other concepts raises the question: would the perpetrators of physical violence be the only ones who use violence with the intention of hurting the victim?
The relationship of unequal power is evidenced in the antecedent terms of sexual violence, highlighting domination, sexism, homophobia, xenophobia, classicism, and ableism (20)(21) .This means that people who occupy positions of greater social vulnerability and, therefore, hold less power in their social relations, are also more prone to victimization by sexual violence.It is noteworthy that sexual violence comprises more than rape or vaginal or anal penetration, being any non-consensual act in the sexual context, directed to women and men (22)(23) .However, it should be noted that understanding that sexual violence can affect women and men does not diminish the need to problematize the issue of female subordination.This type of violence is supported by gender inequality, which removes any kind of power from the female victim; reality data demonstrate the prevalence of female victims (24) .
In turn, psychological violence comprises attitudes that are not physical, however, it is considered present when actions are identified in a relationship that cause psychological, moral and social damage (25) .However, its background points to contexts of relationships between intimate partners, although at no time mention gender relations, it is inferred that, as presented in sexual violence, are directly linked to this issue.
The differences between the concepts and the contexts in which they occur demonstrate that the general term "violence" cannot adequately represent them, at the risk of not giving specificity to the three phenomena and, consequently, diminishing the ability to recognize them in the terminologies that support information systems.
By representing the concepts of the different types of violence addressed in this research by case models, identifying similarities and differences between them, their characteristics, conditions of the events, and possible outcomes, the discussion of the acts involved regarding the phenomenon of violence was raised.Such discussion may help nurses in operationalizing the planning of the assistance provided to women, contributing to its quality, in addition to collaborating in the formulation of theories that support the nurses' performance, whether in practice, research or teaching.
Returning to the issue of inserting CIPE ® into SNOMED-CT, the ontological model used provides for hierarchical relationships between the concepts of interest.That is, using the example that every physical or sexual violence "contains" a psychological violence, the following relationships between objects will exist "Physical Violence" contains Physical, sexual and psychological violence according to Rodgers' evolutionary conceptual analysis Bonamigo VG, Torres FBG, Lourenço RG, Cubas MR "Psychological Violence" and "Sexual Violence" contains "Psychological Violence".To capture the nuances between phenomena, extensive analysis of the concept of interest and related terms is required.
Rather than supporting the ontological logic of SNOMED-CT, ICNP ® will encounter challenges in adding the concepts to nursing diagnoses, outcomes and interventions, especially those that respond to the objectives of SNOMED-CT: the insertion of the concept in a standardized, hierarchical manner with at least one objective definition; the insertion of more than one relationship per concept in order to assist in the definition of other concepts; the support of multiple concept granularities; and that the conceptual definitions remain the same despite the concept context change (4,26) .It is noteworthy that these challenges tend to arise in immature concepts, that is, those that do not present characteristics, outcomes and conditions well described in the literature and that are mostly behavioral (27) .
As study limitations, we highlight that the search was conducted considering a oneyear cross-section, accessing a set of articles available in the CAPES Periodicals Platform, thus, the concepts may not have been described in their amplitude.

FINAL CONSIDERATIONS
The concept of physical violence is related to explicit violent acts, such as punching and kicking on purpose, and is aligned with the generic concepts presented by the WHO and the CIPE ® .The concept of sexual violence can be synthesized as the act of exposing an individual to a sexual situation without his/her consent, highlighting in its background types of prejudices, such as sexism and racism.Finally, the concept of psychological violence can be synthesized as any purposeful act that causes emotional damage to the victim and is present whenever any type of violence is exercised.
The discussion of the acts involved in physical, sexual, and psychological violence, from those that precede such phenomena, to those that characterize the consequences arising from its occurrence, provides an opportunity for nurses to (re)know acts as indicators of violence and relate them to its different types, thus providing an opportunity for optimized and quality care planning.
The cases developed from the analysis of the concepts of interest summarize the complexity of the violent processes studied and contribute to the formation of concepts, still immature, allowing their entry into nursing terminologies.Furthermore, the antecedents, attributes, and consequences of the different types of violence may support the definitions of these concepts in the ICNP ® and their relations with other terminologies.

Chart 2 -
Background terms identified in the definitions, by concept of interest.Curitiba, PR, Brazil, 2021 race, nationality, class, gender, and other dimensions of inequality; conflict; sexism; racism; homophobia; xenophobia; ableism; classism; fear; sexual activity focused on thanking or satisfying the other person's needs.Psychological violence (n=4) Conflict; social relationship; any form of violence in a romantic relationship; obstacles to implementation of laws.n = number of backgrounds Source: Authors (2021).
Physical, mental, spiritual, moral, and social harm; psychological or emotional harm; loss of freedom; difficulty in capturing and proving this type of violence; stress; shame; establishment of fear as a strong element of social relations.
Physical, sexual and psychological violence according to Rodgers' evolutionary conceptual analysis Bonamigo VG, Torres FBG, Lourenço RG, Cubas MR