Clinical TopicsPatient SafetyPediatricsUncategorizedWorkplace Management

Troubling Imagery

Carolyn Jaramillo de Montoya, MSN, CPNP, may no longer be shocked, but she’s certainly exasperated by what she sees during well-child home visits: TVs in the rooms of children as young as 2 years old.
“Young children can’t distinguish between reality and fantasy,” says Montoya, president of the National Association of Pediatric Nurse Practitioners (NAPNAP) and a New Mexico Nurses Association member. And what they increasingly see on TV—in both programming and commercials—is violence without consequences.
To reverse that trend, ANA nurse leaders are campaigning to eliminate violence in advertising that bombards young children and adolescents when they turn on the tube—even during so-called “family” viewing times. The ANA Board of Directors adopted a policy statement urging nurses to advocate against the portrayal of violence in advertising, in part by educating the public about its effect on children’s well-being. Joining ANA are nurses within NAPNAP and the Society of Pediatric Nurses (SPN), who recently signed on to the ANA statement.
“We endorsed ANA’s position on this issue because it fits with our mission of promoting excellence in nursing care of children and their families through advocacy and other measures,” says Sandra Mott, PhD, RN-BC, CPN, president of SPN and Massachusetts Association of Registered Nurses member. “And we’re very concerned about children’s mental health and the amount of violence seen by children in so many venues.”
Throughout the ages, children and adolescents have been exposed to violence, including early children’s programming. Just think of Wile E. Coyote and his endless pursuit of his cartoon character counterpart, the Road Runner. But the amount and type of violence have slowly changed over time. “Some of what’s shown looks like innocent fun, but then it morphs into something more violent,” Mott says. “And there seems to be a lot of one-upmanship in various media—leading to extreme forms of violence.”
The evidence is there
Nurses say that parents can deny children access to certain TV programs, games, and websites—either the old-fashioned way or through technological means—but too much violent imagery is still falling through the cracks during “safe” programming. During Super Bowl XLI, a beer company ad showed a man involved in a friendly game of rock, paper, scissors ultimately throwing a rock at his opponent’s head. Fast forward to this football season; a commercial shown during a Sunday afternoon game contained an image of two kidnapped people crammed into a car trunk and a gun-chase scene. It was promoting an upcoming episode of a prime-time show.
This partnering of athletic events programming and violent imagery in advertising is not new, even though watching sports is considered by many a family activity. The ANA statement references a 2000 study, for example, that examined commercials shown during 15 major league baseball games. Of the 1,550 commercials aired during those games, 137 contained violent interactions. Furthermore, 44 violent commercials, showing blood, fire, explosions, or guns, occurred during four World Series games, an average of 11 per game.
In a 2004 study, researchers discovered that nearly half of the advertising shown during 50 televised sports programs contained some type of unsafe behavior, such as reckless driving or cartoon characters shooting each other. These days, violent imagery is pervasive, even though its effects have been well-documented for some time.
Violence and childhood aggression
In a 2000 joint statement released at a public health summit, the American Academy of Pediatrics and five other prominent medical groups maintained that there is a definite correlation between violence in the media and aggression in children. Specifically, they say that children exposed to violence in this manner are more likely to view violence as acceptable behavior, to become emotionally desensitized to it in real life, and to see the world as a “mean place.” Furthermore, young children are more likely to exhibit violent behavior later in life.An earlier National Television Violence Study had similar findings. “Violence in TV shows, in advertising, in computer games has become part of the culture, and that’s very disturbing,” says Beverly Jorgenson, MSN, RNC, CNP, who served on the ANA Congress and Nursing Practice and Economics working group that drafted the position statement. “A lot of that violence or bullying tends to focus on whoever is weaker, such as those who are younger or female. And often it’s made to look funny.” Adds Montoya, “Violence often is not shown as a painful thing. If someone gets hit over the head with a bottle, he pops right up. If he’s shot, he doesn’t go down. And there’s no going to the ER. So children don’t see the consequences.
“TV gives a very skewed image of life,” Montoya states, “not only in its portrayal of violence, but also the stereotyping of minorities and women in programs and in ads. And with commercials’ emphasis on sex and drinking, like during the Super Bowl, they give an equally skewed picture of what adults like.” As a result, Montoya and her colleagues say that there has been an explosion of mental health problems in children. “There are many causes behind the increase, but TV violence is one of them,” she says.
The ANA statement also points out the link between violent imagery and desensitization to violence. “We’ve seen that played out in our school systems where aggressive behavior, and not empathy, can be the norm,” Montoya says. Mott agrees, saying SPN’s school nurse members are confronted by increased mental health issues, including violent behavior, in students who’ve become acclimated to images of “blood and guts and gore.” “Playground fights are more frequent and a little more serious,” Mott says. “Unfortunately, I think our society as a whole is becoming numb to (entertainment-related) violence.”
The antiviolence campaign
“I find that people look to nurses to help them parent or provide them with information on issues that could affect their families,” says Jorgenson, a South Dakota Nurses Association member and neonatal nurse practitioner who manages a neonatal intensive care unit.ANA’s position statement, available on ANA’s website,, supports nurses in their advocacy to eliminate violence in advertising. In the statement, ANA recommends that registered nurses:
• pursue research activities to gain more evidence on the effects of TV violence on children, adolescents, and families.
• educate families about the potential negative impact that violence in advertising has on both adults and children.
• work collaboratively with their nurse colleagues, as well as through their professional associations and with other stakeholders, to persuade advertisers to remove violent content from their ads.
• undertake a consumer-education campaign to educate the public about the hazards of desensitization in children exposed to violent imagery.
Jorgenson already has been talking with colleagues about lobbying companies to address violence in advertising. “Our commercials should have a rating like a movie or CD,” she says. “They should be held to the same standards of those other media, so parents know what their children might be exposed to when watching TV.”
Jorgenson and other nurses are urging their colleagues to step up their efforts on public education as well. They note they have some strategies to address this issue, and they point to resources available through their specialty nursing organizations.
All nurses say it’s imperative that parents and other adults monitor TV viewing by children and adolescents. “If families have cable TV, then the adults should use the parental code option to block children’s access to inappropriate programming,” Jorgenson says. “Parents should also talk with their children about what programs are OK to watch when they are at someone else’s house.”
Montoya recommends that nurses advocate for the removal of TVs from children’s bedrooms. “If there is a TV in each child’s room, there is no way a parent can monitor what is being watched,” she says. “The TV should not be a babysitter or a parental strategy to help children fall asleep.” She also says nurses can encourage parents to ask their children about what they think is real and what is pretend.
In terms of resources, SPN has a tool kit to help nurses become more active in advocacy efforts and a position statement on “Children, violence, and resiliency” (, according to Mott. The statement focuses on nurses’ unique ability to enhance the coping skills of children and families faced with stressful events and eliminate the potential for violence.
NAPNAP has two initiatives that address limiting children’s TV viewing, which Montoya says should be no more than 2 hours a day. These initiatives are Healthy Eating and Activity Together (HEAT) and KySS: Keep your children/yourself Safe and Secure, which is aimed at preventing psychosocial morbidities in children and teenagers. For more information, visit

Susan Trossman is the senior reporter in ANA’s Communications Department.

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