RESEARCH ARTICLES
The nurse in the elderly care of the family health strategy: meanings of the experience
Amanda Mariza Souza de OliveiraI; Tânia Maria de Oliva MenezesII
INurse. Master degree in Nursing by the Nursing School of the Federal University of Bahia. Nurse of the Family Health Strategy in the municipality of Salvador. Bahia, Brazil. E-mail: mandamaria@ig.com.br
IINurse. PhD in Nursing. Associate Professor I of the Nursing School in the Federal University of Bahia. Leader of the Study Core and Research of the Elderly. Salvador, Bahia, Brazil. E-mail: tomenezes50@gmail.com
ABSTRACT: The family health strategy (FHS) must conduct a full and community care for the elderly, due to the increase of this population. This study aims to understand the meanings of the nurse in the care experienced by the elderly in the Family Health Strategy. This is a qualitative, descriptive and phenomenological study ruled in Martin Heidegger. We interviewed 11 nurses FHS of a municipality of Bahia, in July 2012, after approval by the Ethics Committee of the Nursing of Federal University of Bahia, protocol nº 36768/12. It is highlighted the unit of meaning - Caring for the elderly: the need for training. Nurses from FHS need to guide the elderly care because they feel unsafe in the consultation, as well as meet the elderly specifically in HIPERDIA Program. This study highlights the need for training of FHS nurses directed care to the elderly in a broad way and not just curative.
Keywords: Geriatric nursing; aged; primary health care; philosophy nursing.
INTRODUCTION
The increase in the elderly population is a reality in society from different countries, especially the countries more developed. Japan, for example, coexists with this demographic profile a few years ago, since in this country, life expectancy at birth was 79 years old in 1990, and in 2009, this indicator went to 83 years old, while the Brazilians in the same year, still had 73 years old of expectation of life1.
These data show that in developing countries, as Brazil, the population aging is something recent and reflects the reduction in fertility rates and increasing life expectancy2.
On the increase of the elderly population, it is necessary to guide the actions of the professionals from different areas to meet the specific needs of that group. Health professionals have this reality of ageing reflected in demands for services they act, where the elderly are increasingly present in any level of complexity.
Among those assistance levels, the basic care is taken as the crucial point for the reformulation of the current assistance model, because, through it, it can break with the hospital model, reorganizing the assistive and demand flow, in order to reduce the overhead and by specialized services3.
In this context, the family health strategy (FHS), must be configured as the guidance of this reformulation, including guiding actions of health promotion and disease prevention. In this context, the community care to the elderly must be guided in appreciation of the bond with the family and with family health units, guaranteeing the bond of the elderly with the health system.
In the health care of the elderly, the training of health professionals in the FHS is insufficient, and it is necessary to invest in the development of skills to deal with the challenge of ageing, encompassing prevention, rehabilitation and better understanding of the social and environmental determinants of health/disease process4.
With regard to nursing care, nurses of the FHS have still assisted the elderly following only the general service standards to any user, without considering the particularities of the age5, requiring greater investment in order to deepen the specificities of this knowledge, so that they can qualify the care to this population segment.
In this context, the study aimed to understand the directions of experienced by nurse in the care of the elderly in the family health strategy. The identification and understanding of the experiences of the nurse of the FHS, their possibilities and limitations are the key to reset the daily nursing care to the elderly at this level, in order to guarantee his space and allow the approach of the aging process.
LITERATURE REVIEW
The FHS is currently in a possibility of change of the assistencial model and reorientation of health services, from the basic care, in addition to increasing the possibilities for expansion of the concept of family health in these services6.
To make this possible, the FHS must use the interdisciplinarity and integral and humanized approach, based on local reality and identifying the needs of the population, in addition to collective actions in the community, group activities and participation of users ' social networks7.
As regards the nursing care on FHS, it has from the coordination of nursing staff and community health agents (CHA), managerial activities to care for the individual, through consultation, nursing home visits and activities in the community. Care is right for all, whether they are patients, healthy or not8. All phases of human development should be addressed by nursing care, which includes care to the health of the elderly.
However, FHS nurses face the challenges arising from population aging, with the increase of older people in the health unit, with specific features of the senescence and senility process, competing for children care, pregnant women or women of childbearing age and men, in a context where non-communicable chronic diseases, and infectious diseases, as violence4.
Thus, the FHS professionals require mechanisms that guarantee within this extensive demand for assistance, the health care of the elderly. This requires that the level of basic care focuses mainly on the character education and protection of life and health, with a focus on quality of life of the elderly and his family5. Thus, in the care of the elderly, this should be seen as a historical and social subject, pleading to his family background, the environment and the society in which it is inserted9.
Despite the difficulties, the National Health Policy of the Elderly believes in the importance of the FHS in the care of the elderly, through the confrontation of the shortage of qualified support structures for the elderly and their families, aimed at promoting safe intermediation between the discharge and going home, as well as, the insufficient number of domiciliary care services to frail elderly provided in the Regulations for the Elderly, showing the need to establish a constant and qualified support to those responsible for this care10.
THEORETICAL-METHODOLOGIC REFERENCE
Research of qualitative nature, with phenomenological approach11 and theoretical-methodological reference of Martin Heidegger12.13. The study subjects were 11 nurses of the FHS, in a city in the interior of Bahia, 25 to 38 years old. Inclusion criteria were: nurses enrolled in FHS of the municipality; acting in the Strategy for more than six months; and that accepted participating in the survey after signing an informed consent. Exclusion criteria were: nurses acting in FHS for less than six months.
The collection of testimonials was held in July 2012, through phenomenological interviews with the subjects of the study. In phenomenological research, the collection of testimonies is the encounter between the person who knows and experiences a phenomenon and the researcher that unknown this11. Through this meeting, it is sought the depositions that will lead to further understanding and description of the phenomenon under study.
The interviews were held in a private place, in the health units, where the nurses worked, and on scheduled timetable, through coordination of the basic care of the municipality. A form was used, containing objective questions of characterization of professional and an open question: how have you lived the care of the elderly in the FHS?
Through the interview, it could bring up the object of the study, through the testimony of nurses. The function of the speech is to make accessible the thought and emotions, enabling to show what once was hidden, covered12. Thus, the speeches taken during the interviews were transcribed and performed a thorough reading of them, and the interpretations of analysis of the testimonials.
The analysis and interpretation followed the steps proposed by Martin Heidegger, present in two moments: understanding time and hermeneutic analysis time. The understanding moment search to take the phenomenal, through vague and median understanding of what is expressed in the interviews, constituting the units of meaning. These units of meaning went through a deep understanding on the second moment, hermeneutics, which represents the interpretive movement13.
Interpretive understanding involves the unveiling of the phenomenon, which is not directly shown, needing to go beyond the ontic, in order to demonstrate the sense of being11-14.
The ethical principles were respected during the development of the research, based on Resolution 196/96 of the National Council of Health15. The research was approved by the Ethics Committee of the Nursing School of the Federal University of Bahia under the Protocol 36768/12.
RESULTS AND DISCUSSION
Of the 11 nurses interviewed, most completed graduation three years ago and has post-graduation, three related to family health and collective health. The time of performance in FHS ranged from 6 months to 4 years.
In vague and median understanding, the nurses, speaking of their daily lives, talk about the situations experienced and describe their difficulties. The sense of experienced by the nurse in the care of the elderly in the FHS reveals the need for targeting to the specialty in nursing consultation and training.
I t is realized that FHS nurses need specific knowledge in elderly care, by the fact that during the consultation, they do not follow a script and have the most routine geared towards the HIPERDIA Program, which assisted individuals with hypertension and/or diabetic patients of all age groups.
Health of the elderly we are a little bit lost [...] (E4)
Because they are more particular things, and when there is not routine, there are things that sometimes runs away from the head. I don't know the whole thing, articulated, the script of everything. Because we get so caught up in the HIPERDIA that those other reviews are a little forgotten. (E3)
I have contact with the elderly, with the health of the elderly more on HIPERDIA, here in the unit. My experience is this with the elderly. (E11)
The daily life of the nurses of the FHS, with regard to the health of the elderly, is restricted to the HIPERDIA program assistance, i.e. the vision of being elderly is only to the elderly that shows a pathology and, because of this, they seek the health unit. The HIPERDIA Program is structured to address hypertension and diabetics, who may be elderly or not. Although most of the clients are elderly people, there is no guidance for the health of the elderly, precisely because it is not the focus of the program. Thus, as the nurses provide care to the elderly basically in this program, there is no assistance focused on the specifics of the health of the elderly in the FHS.
About this difficulty in providing guided assistance to the specificities of aging, they also report, as influential factor, the incipient knowledge of graduation.
I don't have much experience in health care for the elderly. In College, health of the elderly was not much. The contents of the College is few. (E6)
In my case, I think the story was [...] a few hours. A technical visit is totally different from you being in practice all the time with these patients. (E1)
The graduation experience restricted to the curricular component in Health Care Nursing of the Elderly, with reduced workload, and with few opportunities to practical assistance, leads to insecurity of these professionals in the care of the elderly. Despite showing interest in a more guided approach, going beyond the care of hypertensive and diabetic patients, the nurses are in insufficient training, a barrier to this more specific assistance.
The contents of geriatrics and gerontology in undergraduate courses must be valued as part of a political-institutional design and not just as a pedagogical question, on the repercussions of the growing population aging for society as a whole16.
Nurses report also the discontinuity of the study in this area, during their professional practice, once the basic care offers courses on family planning, women's health, child health, but nothing focused on capacity building in health of the elderly.
These trainings, as well as the standardization of instruments directed to the care of the elderly population, are key to improving the assistance and development of preventive care, including being requested by the nurses of the FHS.
I think it would be good with a specialist in the area, to say the right things. It is missing. [...] elderly health training I haven't had yet. (E9)
I've had a course on family planning, huh? About women's health, child health. Now I have one about the newborn test, but elderly health we do not have ... They always ask what the people want, there in the Office. There, I always say health of the elderly, because not much I know. Very Little. (E6)
Managers must pay attention to the need expressed by the nurses to be trained for other welfare areas, expanding beyond the health of the woman and child health, which are two important areas of practice of nurses in primary care, but it does not cover the assistance in full, since the strategy is aimed at the care of the family as a whole.
In this way, it is evident the need of managers reflect and optimize the operationalization of public health policies to the elderly, scheduling and conducting guided and specific trainings for care in old age and expanding financial resources in order to improve the actions in this area17.
In addition to promoting a greater knowledge into the health of the elderly, the courses are useful tools for changing the profile of elderly served by the FHS, stimulating new vision of professionals about what is to be careful being elderly.
What I have observed is that the we have held a lot on the issue of elderly hypertensive and diabetic, mainly ... Basically, I don't see other view otherwise. (E3)
The vision of the elderly patient is part of these nurses experienced in FHS, and reflects in the care provided, since the being-ill requires a healing assistance, leaving the preventive in a second place. To change this perspective is critical, and to this end, trainings on geronto-geriatric area are indispensable, because the incipient knowledge makes the vision of these professionals being restricted to the elderly patient.
It is possible to observe in their own testimonials that nurses recognize the importance of training in changing how to see being elderly, and consequently the type of care provided.
We did a training. The Secretariat gave it to us, to learn about the elderly, independent of the disease. Because, in fact, what we had here was the elderly as hypertensive, diabetic, as a really sick person. Then, after we had this training, and began to see, to introduce the health of the elderly. (E2)
It is through knowledge that it is promoted a change in the look of these professionals, becoming possible to another type of care to the elderly in the FHS. A service based on changes specific to the aging process, and that values prevention as a fundamental strategy in ensuring a healthy aging and quality of life as pursued in this stage of the course of life.
The nurse of the FHS must realize that his role in the care to being-elderly goes far beyond the exchange of recipes and guidance on the care of feeding, environment, blood pressure and blood sugar. They must get a general assessment of that individual, and, from there, to provide the necessary care and referrals. However, this extended care is only possible with trainings in the area geronto-geriatric.
In addition to the trainings, the nurses highlighted the importance of using standardized instruments for assessing the health of the elderly. In the FHS of the municipality in which this study took place 2 months before starting the interviews, the nurses began using a questionnaire for evaluation of visual acuity, auditory and cognitive ability of the elderly. Regarding the use of this questionnaire they report:
At least we standardize what we will ask the patient. Having all written here (E4).
Before we had no form, so not always we focused directly, we do it automatically. I'm not telling you this: Oh, I did all the development concerned with the elderly. No. We did the whole evolution as an adult. (E1)
It has that manual, and I'll tell you the truth, it was the only one that I didn't read, it was the only one I took it the day we did the training of that form. (E6)
Although there is a Notebook of Basic Care with specific guidelines for assistance of the elderly7, the training and the use of standardized assessment instruments are still required and make a difference in the care of being-elderly in the FHS.
It is understandable, then, the need to develop strategies for maintenance and expansion of knowledge on geronto-geriatric nursing in FHS, in order to encourage improvement in care to this segment of population in the community.
Meaning of the experience
In this study, the nurses in their daily life is shown in a relationship of care to the elderly, theyr are to be with the elderly. “[...] The basis of this be-in-world, determined by the world is always the world shared with others. The world of presence is the shared world [...]”13:175. The nurse in the FHS share with the elderly who is the one engaged. “On being-with and for others, there is therefore an ontological relationship between presences [...]”13:181. The nurse lives this facticity, i.e. she is on what is determined and she cannot escape. “The expression what is determined should indicate the facticity of responsibility [...]”13:189. The nurse is shown as she is first and most of the time, in their daily lives.
He is one of the professionals responsible for the care of the elderly at home. The concern is a way to relate to each other, take care of each other's existence, which is only possible through an engaging and meaningful relationship and its basic characteristics have regard for each other and have patience with the other13.
In their daily lives, the nurse eventually feels difficulty to exercise care. As they do not perform a type of care directed to the elderl, that is, assisting is the general way, there is not intentionality, as structure of lived experiences by consciousness, there is not a guide to the being-elderly care. Intention means to addressing, therefore, every experience, every act of consciousness is intentional18.
The nurses, in their practice, are in the way of being of the occupation. “The ontological nature of the occupation is not suitable of being-with, although this way of being is a being to the being coming to date within the world as occupation [...]”13:177. To take care of the elderly, the nurse care, too. “Take care of food and clothing, treat the sick body is also a concern [...]”13:178.
The nurses also have disabled concern, because they are attached to the service of children and pregnant women recommended and are not guided to the elderly care. “We are first of all and most often, what determine us to be. Everyday coexistence remains between the two extremes of positive coexistence: dominant replacing and liberating territorial cohesion [...]”13:174.
Thus, considering the everyday as the way of being in the presence, of beginning and in most cases, keeps, i.e., as “live your day”13:172, the being-nurse of FHS shows up on a daily basis is that does not have being-elderly care in its entirety, by deficiencies in their university education, as well as after that becomes professional. “In his being factual, the presence is always how and what he already was. Explicitly or not, the presence is always his past [...]”13:57.
Furthermore, the absence, in the everyday, for the being-elderly care, independent of pathologies reveals difficulties in assistance, as it is not something common in their practice. The being there, in his occasional, can be seen and presented in very different perspectives12.
In this possibility that the nurse, in their daily lives, can guide care to the elderly under various perspectives: be patient; be healthy; be-with-disability, among others.
The care restricted to the ill being-elderly reflects the vision of the nurse under a particular perspective only, setting aside all other possibilities of this being be shown, and limited to assistance in the FHS a portion of elderly population already affected by a pathology.
From a certain perspective, it can only see one side, an aspect of the thing, which merges with the other possible aspects of sensitivity; in each case, a different aspect is presented in relation to the observer's position12.
However, the nurse cannot meet this being like everyone, just as the parts, the hues. The whole can be presumed, imagined, created. In this way, the nurse of the FHS should be open to the various manifestations of being, and, according to the needs expressed, or hides, develop an expanded and understanding care to the elderly in the FHS.
CONCLUSION
Through the testimonials, it can be understood that the sense of experience in care nurse the elderly of the FHS reveals insecurity derived from the incipient knowledge about the health of this population segment, and a daily, in which the integral care to being-elderly is absent, limiting assistance to this population to HIPERDIA program, characterizing one of the main objectives of the FHS, the prevention.
It is evidenced the need for training of the FHS nurses for the care of the elderly guided to the specificities of the aging process, going beyond the restricted vision of care in healing dimension.
Covering preventive health of the elderly in the FHS is a challenge to these professionals, and that can be overcome from the training and use of guiding instruments of assistance. Through these strategies, the nurses should feel more confident and willing to perform a service to the elderly in their communities.
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