ORIGINAL RESEARCH

Care for hospitalized elderly patients: implications for nursing team

Silmara Meneguin^I; Paula Fernanda Tieko Banja^II; Maria de Lourdes da Silva Ferreira^III

^I Ph.D., Professor. Nursing Program, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista. São Paulo, Brazil. E-mail: silmeneguin@fmb.unesp.br
^II RN. Nursing Program, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista. São Paulo, Brazil. E-mail: p.banja@ig.com.br
^III Ph.D. Nursing Program, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista. São Paulo, Brazil. E-mail: malusa@fmb.unesp.br

DOI: http://dx.doi.org/10.12957/reuerj.2017.16107

ABSTRACT

Objectives: to apprehend the perception of nursing professionals about the meaning of being elderly and to identify the facilities and difficulties faced in caring for hospitalized elderly patients. Method: qualitative research, with 34 nursing professionals, working in a medical clinic ward, at a public hospital in São Paulo State, Brazil. Data were collected through a semi-structured interview, and submitted to the content analysis Results: the perception of the elderly was related to age, physical appearance, degree of dependence, lack of affection and insecurity. Facilities were related to disease acceptance, treatment, passivity and trustiness in the team. Dependence, habits, relationship with the companions, coexistence with the abandonment and insufficient time for the care were considered limiting factors for the care. Conclusion: the study participants have stereotyped perception of the elderly; difficulties and facilities in care are associated to the aging process, illness and institutionalization.

Keywords: Aged; nursing care; hospitalization; aging.

INTRODUCTION

Aging is a multidimensional process, which is conceptualized as a set of morphological, physiological, biochemical and psychological changes, which can be interpreted simultaneously as gains and losses and which mostly depend on the life history and adaptation of the individual to the environment.^1,2

Estimates from the World Health Organization (WHO) indicate that, by 2025, approximately 1.2 billion people will be over 60 years old worldwide. ³ In this scenario, Brazil will be the sixth country with the largest number of elderly, reaching a milestone of 33.4 million in the year 2025. According to data from the Brazilian Institute of Geography and Statistics (IBGE) in 2010, among the 190 million Brazilians, 18 million were elderly.⁴

This population aging gives rise to a new epidemiological profile because, although old age does not mean disease, but rather a phase of life with its own characteristics and values, in which the individual experiences changes, it is known that the elderly have a greater susceptibility to disease and, therefore, end up constituting a representative part of hospitalizations.^5,6

Given this reality, this investigation seeks to answer the following guiding questions: How does the nursing team perceive being elderly? What are the facilities and difficulties the nursing team faces in care for the hospitalized elderly?

In view of the above, the objective of this research was to apprehend the nursing professionals' perception about the meaning of being elderly and to identify the facilities and difficulties faced in the care given to the hospitalized elderly.

Due to the degenerative aging process, there is greater susceptibility to disease, which leads to changes in the daily life of the elderly, demanding specific care, which requires greater attention. Often, hospital admissions are necessary. Within the scope of the Unified Health System, the elderly appear as one of the main users of the service in terms of hospitalization.⁷

With the hospitalization process, the elderly become more vulnerable and their autonomy even more restricted, due to the hospital scenario, with its norms and routines and its highly technological apparatus. Hospitalization is usually followed by a decrease in functional capacity and changes in the quality of life, which are often irreversible.⁸

Hospital admission can be considered a disruption factor for the elderly, as the actions and interactions occur in a context determined by situational and structural influence.8 In addition, the hostile environment of these services contributes to enhance their physical fragility and their emotional vulnerability. In addition, prolonged bed rest during hospitalization also predisposes the elderly to greater complications, which contributes to the possible increase in the dependence on the nursing staff.^9,10

In the hospital environment, when confronting the disease and the treatment, patients come to have contact with people who are not part of their social structure and are faced with circumstances that interfere in their daily lives. The aspects that support this relationship are surrounded, on the one hand, by the essential needs of care and, on the other, by a hierarchically determined and dimensioned professional activity.⁹

In this context, the multidimensional nature of care needs to be taken into account, valuing the human being as a whole and rescuing humanistic values in health care.^8-10

This study shows that the nursing professionals' view on the elderly is mostly stigmatized, limited and pessimistic, opposing the demands for quality care to the hospitalized elderly, which require differentiated care and greater sensitivity from the professionals.^11,12

METHOD

This is a descriptive study with a qualitative approach. The nursing team professionals of the medical inpatient service at a public university hospital in the interior of São Paulo were considered eligible for the study, provided that they complied with the following inclusion criteria: to be practicing the professional activity at the time of data collection and to agree to participate in the research. Professionals who were unable to complete the interview were excluded.

The inpatient service offers 40 beds for clinical patients in diverse specialties. At the time of the research, the nursing team consisted of 42 professionals, nine of whom were nurses, 21 were technicians and 12 were auxiliary nurses.

For the data collection, a semistructured interview was used, consisting of two parts, the first one to characterize the participants and the second one composed of three questions about care for the hospitalized elderly, namely: In your perception, what does it mean to be old?; Tell me what contributes to facilitate the care given to these patients?; What are the difficulties faced in care for an elderly patient?

The interview was held at a single moment, in a private setting and after work. The audio was fully recorded using a voice recorder and the researcher was careful not to exert any influence on the interviewee's response.

Sample closure was determined based on theoretical saturation, that is, the inclusion of new participants in the survey was suspended when the data obtained no longer offered significant contributions to the study. ¹³

For the treatment of the collected data, we used the content analysis method, developed by Bardin, which considers the categorization process and the classification of elements that are grouped in a set. It consists of the following steps: pre-analysis, exploration of the material and treatment and interpretation of the results.¹⁴

In this study, we chose to identify the interviewees' statements using the letter I (interviewed) followed by the number they received in the transcription of the interviews.

The study was carried out after approval of the project by the Research Ethics Committee of Botucatu Medical School, under protocol 120/20/2011, in accordance with the ethical standards required by National Health Council Resolution 466 from 2012.¹⁵

RESULTS AND DISCUSSION

Thirty-four nursing professionals participated in the study, 7 (20.6%) of whom were nurses, 18 (52.9%) were technicians and 9 (26.5%) were auxiliary nurses. Of these, the majority were female 30 (88.2%), in the age group of 20 to 39 years and with one to 10 years of professional experience.

For a better understanding of the qualitative results, the units of meaning were grouped into three categories: perception of the elderly, facilities in care for the hospitalized elderly and limiting factors for care.

Perception of the elderly

In this category, we emphasized: age and physical appearance, degree of dependence, lack and insecurity.

Regarding age and physical appearance, the testimonies reveal that the team identifies the elderly by age and physical appearance, although they demonstrate not being clear about the age group they fit into. This finding is also revealed in another study, according to which aging is not a simple passage of time, but a process marked by biological, psychological and social changes that occur in the individual, in the course of time.¹⁶

The biological changes of the aging process include anatomical and functional changes. Among the anatomical changes, the most notable are the alterations of the facial attachments, baldness, gray or white hair, skin and physical postural problems.¹⁷

In this study, although the anatomical changes are not specified with precision in the respondents' discourse, these induce the perception of advanced age.

The degree of dependence was another aspect identified. For some participants, the condition of being dependent is also tied to being elderly. And probably because they provide direct care to elderly patients in pathological conditions, they refer to them by linking them to the care needs.

In many cases, even when in good health, the elderly, due to the aging process, can become dependent and vulnerable when faced with a hospital environment, which can be stressful. A study conducted with 100 functionally independent elderly individuals aged 60 to 93 years showed that care influenced by the harmful belief that aging is a degenerative process contributes to the label of the elderly as a less able adult, a misconception that can compromise the care.¹⁸

Another important aspect was the perception of the elderly as a needy and insecure person. The frailty of the elderly person affected by some disease, and also dependent on the other, increases the difficulty to make autonomous decisions, as evidenced in a study developed with elderly from two hospitals in the North of Rio Grande do Sul.⁸ Nevertheless, it should be highlighted that part of the difficulties the elderly people face is related to the culture and devalues and limits them. Thus, the stigma and social exclusion strongly affect the elderly, with negativism as the main consequence. Nevertheless, it should be taken into account that this negative way of facing the aging process can be linked to the sociocultural context it is inserted in.¹¹

Health professionals often have inappropriate and paternalistic attitudes towards the elderly and consider them incapable, factors that contribute to diminish autonomy and prevent the promotion of greater dependence. ^11,12 Possibly, these denominations the professionals attributed to the elderly are related to the very weight of aging, disbelief in the continuity of life, loss of vital relationships, feeling of uselessness, denial of the aging process, fear of death, solitude and isolation.

Facilities in care for the elderly

From the analyzed narratives, the following was identified in this category: acceptance of the disease and treatment compliance, collaboration and passivity, trust in the team and cordiality.

The idea of acceptance of the disease and treatment compliance emerges from the discourse as facilities that condition care.

Collaboration and passivity have also been highlighted as facilitators of care, although passivity may contribute to dependence and loss of autonomy.

The changes generated by hospitalization may increase passivity, which can be considered as an important indicator in the care for the elderly, but its meaning is ambiguous as, at the same time as it facilitates the team's performance, it increases the patients' dependence and reduces their autonomy.¹⁹

One form of violence to the elderly in society is their treatment as infants. When one says that the elderly return to being children and need to be treated as such, even if this is done for the sake of kindness and good care, they are deprived of the possibility to command their own life, of recognizing themselves as the owners of their own history, as evidenced in recent research with adolescents from public and private schools.²⁰

To that end, health professionals need the technical skills to establish productive, positive and needs-based dialogue and to foster care in which the elderly are active participants.

As for trust in the team and cordiality, it was noticed that care actions are favored by the trust the patient places in the team, which can result in mutual rewards, as professional recognition contributes to personal satisfaction and tends to encourage good practices. Thus, the patient receives care and gratifies the professional's action, resulting in feedback.

Limiting factors for care

In this category, the following factors were identified: limitations and dependence, behavior and habits, relationships with companions, coexistence with suffering and abandonment, and insufficient time for care.

Limitations and dependences are related to diseases and the aging process.

When hospitalized, the degree of limitation and the dependence of the elderly tend to increase, making care difficult and requiring greater professional dedication and greater availability of time. Nevertheless, as a result of concerns with the work demands, often, the nursing professionals use strategies to speed it up, adopting improper attitudes that induce the client's dependence, not being the mediator but the executor of the activities.

In this context, training the nursing team for care to the elderly is fundamental because they represent a special group, due to their peculiarities and dependence. Nevertheless, the daily routine of care relations in hospital institutions, which is almost always mechanized and indifferent, does not foster the perception of the other as a human being, often compromising the patient's dignity and self-care.⁸

The difficulties in the care for the elderly are also related to their behaviors and habits. Therefore, knowing the elderly as holistic beings is of fundamental importance for individualized care.

The hostility present in the hospital environment causes intense stress in the elderly and may lead to different behavioral reactions, as revealed in the survey conducted with 15 elderly people at a public hospital in the interior of the state of Rio de Janeiro.²¹

Regarding the relationship with the companions, the nursing team does not acknowledge their importance for the hospitalized elderly, despite the legality of their presence. Nevertheless, the caregiver can contribute to the care provided in the hospital setting as a lay caregiver.

In addition, in humanized care, the family should be an integral part of care. A study shows that positive affective relationships with family members are fundamental for the quality of life of the elderly and avoid isolation, which can cause distress and loneliness.²²

The coexistence with the suffering and the abandonment of the hospitalized elderly were important factors identified in this category.

Then, the importance of the nursing team's presence was evidenced as a means to contribute to minimize the suffering of the elderly during the hospitalization. Holistic caring for the elderly and in a humanized way, with respect, appreciation and affection should therefore be a primordial step of care.

Finally, the professionals also pointed out insufficient time for care as a difficulty, highlighting the deficiency in the quality of care due to the overload of work, deficient human resources, advanced age of most patients and high degree of dependence.

It should be emphasized that the service where this study was carried out involves several specialties with different degrees of care complexity, and whose staffing does not contemplate the demands of the clientele, as explained in the team members' testimonies.

In this scenario, permeated by incongruities and challenges, the care policies for the elderly should take into account their inclusion in the hospital, considering their values, singularities and limitations. In addition, there is a need to reassess the limits of actions in the organizational space of care, in order to respect the citizenship and autonomy of these clients.²³

CONCLUSION

By the interpretation of the meanings emerged in the discourse, it was evidenced that the participants had a stereotyped perception of the elderly. Nevertheless, the elderly are acknowledged as a differentiated group, with peculiarities that require special attention of professionals to meet their health needs with quality.

The difficulties and facilities in care were linked to the process of aging, illness and institutionalization. The growth of the elderly population has resulted in more complex health demands, which refer to the need for investments and reorganization of care at the primary and secondary levels, in order to reduce their hospitalization rate.

Based on the assumption that the nurse is the professional responsible for planning and organizing care, it was considered relevant to know the opinion of the other nursing professionals involved in care, in an attempt to provide support to improve the quality of nursing care provided to the elderly and enhance the visibility of this practice.

Although the research was carried out with a small number of participants and in a single health service, the results found may support other studies that broaden the discussion about the nursing team's perception of elderly patient care.

REFERENCES

1. Mitnitski A, Collerton J, Martin-Ruiz C, Jagger C icki TV, Rockwood K, Kirkwood TBL. Age-related frailty and its association with biological markers of ageing. BMC Med. [internet] 2015 [cited in 2017 Apr 28]; 13:161. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4499935/

2. Khaje-Bishak Y, Payahoo L, Pourghasem B, Jafarabadi MA. Assessing the quality of life in elderly people and related factors in Tabriz, Iran. J Caring Sci . [internet] 2014 [cited in 2017 Apr 28]; 3(4): 257–63. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4334177/

3.World Health Organization. Envelhecimento ativo: uma política de saúde. Brasília (DF): WHO; [internet] 2001 [cited in 2017 Apr 19]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/envelhecimento_ativo.pdf

4.Instituto Brasileiro de Geografia e Estatística. Censo demográfico 2010 [Internet]. Rio de Janeiro: IBGE; 2017 [cited in 2017 Apr 01]. Available from: http://www.ibge.gov.br

5.Schimidt TCG, Silva MJP. Percepção e compreensão de profissionais e graduandos de saúde sobre o idoso e o envelhecimento humano. Rev Esc Enferm USP. [internet] 2012 [cited in 2017 Apr 19]; 46(3): 612-7. Available from: http://www.scielo.br/pdf/reeusp/v46n3/12.pdf

6.Prochet TC, Silva MJP. Percepção do idoso dos comportamentos afetivos expressos pela equipe de enfermagem. Esc Anna Nery. [internet] 2011 [cited in 2017 Apr 19]; 15(4): 784-90. Available from: http://www.scielo.br/pdf/ean/v15n4/a18v15n4.pdf

7.Lebrão ML, Laurenti R. Saúde, bem-estar e envelhecimento: o estudo SABE no município de São Paulo. Rev Bras Epidemiol. [internet] 2005 [cited in 2017 Apr 19]; 8(2): 127-41. Available from: http://www.scielo.br/pdf/rbepid/v8n2/05.pdf

8. Admi H , Shadmi E , Baruch H , Zisberg A . From Research to Reality: Minimizing the Effects of Hospitalization on older adults. Rambam Maimonides Med J . [internet] 2015 [cited in 2017 Apr 19]; 6(2): e0017. Available from : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4422456/

9.Both JE, Leite MT, Hildebrant LM, Beuter M, Muller LA, Linck CL, et al. Qualificação da equipe de enfermagem mediante pesquisa convergente assistencial: contribuições ao cuidado do idoso hospitalizado. Esc Anna Nery. [internet] 2014 [cited in 2017 Apr 19]; 18(3): 486-95. Available from http://www.scielo.br/pdf/ean/v18n3/1414-8145-ean-18-03-0486.pdf

10.Izaias EM, Dellaroza MSG, Rossaneis MA, Belei RA. Custo e caracterização de infecção hospitalar em idosos. Ciênc saúde coletiva (online). [internet] 2014 [cited in 2017 Apr 19]; 19(8): 3395-402. Available from: http://www.scielo.br/pdf/csc/v19n8/1413-8123-csc-19-08-03395.pdf

11.Cunha JXP, Oliveira JB, Nery VAS, Sena ELS, Boery RNSO, Yarid SD. Autonomia do idoso e suas implicações éticas na assistência de enfermagem. Saúde em Debate. [internet] 2012 [cited in 2017 Apr 19]; 36(95):657-64. Available from: http://www.scielo.br/pdf/sdeb/v36n95/a18v36n95.pdf

12.Piexak DR, Freitas PH, Backes DS, Moreschi C, Ferreira CLL, Souza MHT. Percepção de profissionais de saúde em relação ao cuidado a pessoas idosas institucionalizadas. Rev Bras Geriatr Gerontol. [internet] 2012 [cited in 2017 Apr 19]; 15(2):201-8. Available from: http://www.scielo.br/pdf/rbgg/v15n2/03.pdf

13.Minayo MCS. Amostragem e saturação em pesquisa qualitativa:consensos e controvérsias. Revista Pesquisa Qualitativa. [internet] 2017 [cited in 2017 Apr 19]; 5(7):1-12. Available from: file:///C:/Users/user/Downloads/82-250-1-PB.pdf

14.Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011.

15.Conselho Nacional de Saúde (Br). Resolução nº 466, de 12 de dezembro de 2012 [Internet]. Aprova as diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. Diário Oficial da União. 2012 Dec 12 [cited in 2017 Feb 10]. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/cns/2013/res0466_12_12_2012.html

16.Deslandes A. The biological clock keeps ticking, but exercise may turn it back. Arq Neuropsiquiatr. [internet] 2013 [cited in 2017 Feb 10]; 71(2):113-8. Available from: http://www.scielo.br/pdf/anp/v71n2/11.pdf

17. Ekerdt DJ, Koss CS, Li A, Münch A, Lessenich S, Fung HH. Is longevity a value for older adults? J Aging Stud. [internet] 2017 [cited in 2017 Feb 10]; 43:46-52. Available from: http://www.sciencedirect.com/science/article/pii/S0890406517302554

18.Ferreira OGL, Maciel SC, Silva AO, Sá RCDN, Moreira MASP. Significados atribuídos ao envelhecimento: idoso, velho e idoso ativo. Psico-USF. [internet] 2010 [cited in 2017 Apr 19]; 15(3):357-64. Available from: http://www.scielo.br/pdf/pusf/v15n3/v15n3a09.pdf

19.Santos RAAS, Corrêa RGCF, Rolim ILTP, Coutinho NPS. Atenção no cuidado ao idoso: infantilização e desrepeito à autonomia na assistência de enfermagem. Rev Pesq Saúde. [internet] 2016 [cited in 2017 Apr 19]; 17(3):179-83. Available from: http://www.periodicoseletronicos.ufma.br/index.php/revistahuufma/article/view/6793/4335

20.Pereira RF, Freitas MC, Ferreira MA. Velhice para os adolescentes: abordagem das representações sociais. Rev bras enferm (online). [internet] 2014 [cited in 2017 Apr 19]; 67(4):601-9. Available from: http://www.scielo.br/pdf/reben/v67n4/0034-7167-reben-67-04-0601.pdf

21.Caldas CP, Teixeira PC. O idoso hospitalizado sob o olhar da teoria de enfermagem humanística. Cienc Cuid Saúde. [internet] 2012 [cited in 2017 Apr 19]; 11(4):748-57. Available from: http://periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/21657/11515

22. Gott M, Wiles J, Moeke-Maxwell T, Black S, Williams L, Kerse N, Trussardi G. What is the role of community at the end of life for people dying in advanced age? A qualitative study with bereaved family carers. Palliat Med. 2017; 1:269216317735248. doi: 10.1177/0269216317735248.

23.Gautério DP, Vidal DAS, Barlem JGT, Santos SSC. Ações educativas do enfermeiro para a pessoa idosa: estratégia saúde da família. Rev enferm UERJ [Internet] 2013 [cited in 2017 Apr 19]; 21(Esp.2):824-8. Available from: http://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/12302