Constitution of autonomy discourse of older person in the daily life of a Long-Term Care Facility for the older person

Abstract

Objective

to analyze the constitution of autonomy discourse of the older person in a Long-Term Institution, from the perspective of professionals and institutionalized older person women.

Method

qualitative research, developed from the perspective of the post-structuralist framework, fulfilled in a philanthropic institution in the city of Belo Horizonte, Minas Gerais, Brazil. Data were collected, from January to March 2018, through semi-structured interviews with 13 professionals and seven older person women, document analysis and observation and were submitted to discourse analysis.

Results

the effects of institutionalization on the constitution of the older person’s autonomy can be observed in the speeches of the older person and professionals. The Institution is a place of discipline, with well-established routines, with little space for older person women to make decisions. Their autonomy is forgotten, because routines, in a way, cover up their desires, their choices and their own freedom.

Conclusion

for a proper functioning of the structure, limits and rules are necessary. However, it is important to consider that the standards are not used solely as an instrument for controlling and restricting the older person women’s decision-making exercise. The epidemiological transition requires from institutions changes in their daily practices, arising from specific public policies for institutions, with a clear definition of their role and guidelines for a qualified practice.

Keywords
Elderly; Home for the Aged; Personal autonomy; Institutionalization; Aging

Resumo

Objetivo

analisar a constituição do discurso da autonomia da pessoa idosa em uma Instituição de Longa Permanência, na perspectiva de profissionais e de idosas institucionalizadas.

Método

pesquisa qualitativa, desenvolvida na perspectiva do referencial pós-estruturalista, realizada em uma instituição filantrópica da cidade de Belo Horizonte, Minas Gerais, Brasil. Os dados foram coletados no período de janeiro a março de 2018, por meio de entrevista semiestruturada, com 13 profissionais e sete idosas, análise documental e observação e foram submetidos à análise de discurso.

Resultados

os efeitos da institucionalização na constituição da autonomia das idosas pode ser observado nos discursos das idosas e dos profissionais. A Instituição se constitui num local de disciplina, com rotinas bem estabelecidas, com pouco espaço para a tomada de decisão das idosas. Sua autonomia fica esquecida, pois as rotinas, de certa forma, encobrem seus desejos, suas escolhas e sua própria liberdade.

Conclusão

para um funcionamento adequado da estrutura, limites e regras fazem-se necessários. Entretanto, é importante considerar que as normas não são utilizadas, unicamente, como instrumento de controle e cerceamento do exercício de tomada de decisão das idosas. A transição epidemiológica exige das instituições mudanças em suas práticas cotidianas, advindas de políticas públicas específicas para as instituições, com a definição clara de seu papel e diretrizes para uma prática qualificada.

Palavras-Chave:
Idoso; Instituição de Longa Permanência para Idosos; Autonomia Pessoal; Institucionalização; Envelhecimento

INTRODUCTION

Brazilian public health policies privilege the permanence and care of the older person at home, as a way to promote health, prevent disabilities and maintain the functional capacity of the dependent older person¹. However, with the changes in society and in the family structure, this care, previously restricted to the family nucleus, particularly to women, has taken on a different profile, given the demands of the market and the expansion of women’s participation in the labor market².

In this context, the institutionalization of the older person becomes an alternative to be considered, with a consequent increase in the demand for places in Long Term Care Facilities for the Older Person (LTCFs).

Historically, these places are recognized as places of isolation, social and generational segregation, in which individuals are deprived of freedom³. Institutions of this nature make up the list of total institutions, that is, institutions that serve as residence for a certain number of individuals in a similar situation, for a considerable period of time, during which they are separated from society in general and lead a confined lifetime⁴. Total institutions are oppressive environments, where the recluded have their daily lives largely controlled, with their autonomy being weakened⁵.

Autonomy, a central component of the general well-being of the older person, is strongly anchored in meeting the basic needs of an individual, influencing their dignity, integrity, freedom and independence⁶. Even in the face of a variety of conceptual issues, in general, theories about autonomy converge in two essential conditions: freedom, which refers to the independence of controlling influences, and agency, which is the ability to act intentionally⁷.

Autonomy refers to the issue of the subject’s relationship with the other and constitutes the tension between the established society and the instituting society, so that the idea of autonomy can only be conceived in the analysis of the historical and social process⁸. In this sense, the context of population aging should lead us to reflections on this process, which encompasses issues related to autonomy within the institutionalization of the older person, as it is estimated that 1% of Brazilians over 60 years of age reside in LTCFs⁹.

Older people may have their autonomy restricted with institutionalization, since the routines imposed in this scenario are factors that may be associated with the possibility of reducing the exercise of their own will⁹. This justifies the relevance of investigating, from different perspectives, the constitution of the discourse of autonomy of institutionalized older people. Thus, this article aimed to analyze the constitution of the discourse of autonomy of older people in a Long-Term Facility, from the perspective of professionals and institutionalized older women.

METHOD

The present study is a qualitative research, which uses post-structuralism as a theoretical-philosophical framework. Qualitative research delves into the intensity, uniqueness and meaning of things, in a cycle that does not close, as all research produces knowledge and generates new questions¹⁰. These questions are interconnected with the perspective of post-structuralism, since its foundation is to question reality itself, who are the individuals who constitute it and what social relations are established in a given scenario¹¹. In addition, post-structuralism allows for a reflection on the concepts used by society, which are not accepted as universal truths, but rather as a result of changes in power relations¹².

The research was carried out in a philanthropic LTCF in the city of Belo Horizonte, Minas Gerais (MG), Brazil, where only women reside. Two previous visits were made to the institution so that it was selected as a research field. This fact was due to the institution’s interest in the topic to be addressed by the research.

The Institution has a capacity for 30 older women and, at the time of data collection, it had 28 institutionalized women, aged between 60 and 93 years. The multidisciplinary team responsible for the care of these older women was composed of: a nurse, four nursing technicians, six caregivers, a physician, a social worker and a psychologist. Research participants were informed about the institutional affiliation of the researchers to a Federal University of Minas Gerais and about the topic of the research they proposed to develop at the ILPI.

Study participants were institutionalized older women and professionals involved in daily care. Inclusion criteria for the older women were: being 60 years old or older, residing in the institution for at least three months, having verbal fluency that allowed dialogue and having a result of the Mini Mental State Examination with a score of 20 for illiterate people, 25 for people with one to four years of education, 26.5 for those with five to eight years of education, 28 for individuals who studied from nine to 11 years and 29 for those with more than 11 years of education¹³. The inclusion criteria for the professionals were: being a professional involved in the daily care of the older women, working at the institution for at least three months, excluding workers exclusively involved in administrative activities and those in general services.

To define the sample, the criterion of data saturation was used, that is, the inclusion of participants was interrupted when it no longer led to obtaining new information¹⁴ on the constitution of the discourse of autonomy of institutionalized older women. Thus, saturation was achieved with the participation of seven older women and 13 professionals.

The age of the older women participants ranged from 71 to 92 years, with institutionalization time from one to 13 years. As for education, three had not completed elementary school, one had completed elementary school, two had completed high school and one had higher education. Of the professionals, 12 were women and one man, aged from 26 to 65 years old and working at the institution between one and 30 years. Five had higher education and eight medium level.

The research team consisted of a researcher with a doctorate in Nursing, a master’s student in progress, and a nursing student in a scientific initiation program, who was guided and supervised by the nurses in all activities of which she participated.

Data collection took place from January to March 2018, through semi-structured interviews, with an average duration of 15 minutes, in addition to field observation. At first, the interviews were conducted by the master’s researcher, together with the nursing student. Both were trained by the researcher PhD in Nursing on the technique of conducting the interviews.

The establishment of rapport aims at welcoming the researched, so that they feel confident and favor their participation in the research¹⁵. The technique was applied by the researchers to respectfully approach the older women and professionals, in a reserved and welcoming environment.

The older women and professionals were approached to conduct the interview during visits to the Institution, with a day and time being scheduled in advance. One older woman gave up on participating in the research and one professional was excluded for working at the institution for less than three months.

The older women’s interview script contained the following guiding questions: 1) Where did you live before coming to this Institution? 2) Whose decision was it for you to come live here? Why? 3) Do you feel able to make decisions about the things you need to do on a daily basis? Why?

In the professionals’ script, the questions were: 1) What is it like for you to work in an LTCF? 2) How is your daily work at the Institution? 3) Do you consider that the seniors of this LTCF are able to make decisions about the things they need to do in their day-to-day? Why?

The interviews were carried out individually, in a reserved environment at the LTCF, with the presence of the researchers and the interviewee. They were recorded in a Media Player equipment and later transcribed by the master’s nurse and by the undergraduate student. For observation, visits were made three to five times a week during the period of data collection, being recorded in a field diary. The field diary was filled out during the interviews and concomitantly with the observation of the researchers. The observation included weekends, alternating the periods of morning, afternoon and evening, until approximately 8:00 pm.

For analysis purposes, all collected material was treated as text. The interviews were transcribed in Microsoft Word, converting them into narrative texts, and the field notes constituted texts of observation of the daily practices of the LTCF.

Data were submitted to discourse analysis (DA), which focuses on language and its use¹⁶, which was used in this study to explore the constitution of the discourse of autonomy of the older women. Discourses are formed by elements that do not present a principle of unity, and it is up to the DA to seek the rules that are capable of governing its formation, which enables the determination of the elements that make up the discourse¹⁷. The emphasis of DA is the analysis of the internal knowledge of the practice of a given society, which is expressed through its language, understanding that speeches and texts are social practices¹⁸.

In the constitution of their speeches, the subjects elaborate a repertoire of discursive resources with different strategies. Such descriptions are not limited to mere reports of a scene, thing or person, but are oriented towards the action that constitutes them and, therefore, contribute to creating the realities experienced by people¹⁶. The associations and analyzes performed involved the interpretation of texts based on the data and their implicit meaning, based on the post-structuralist framework¹⁹.

The first stage of the analysis consisted of the repeated and exhaustive reading of the texts produced from the data by the researchers involved in the investigation. From then on, discussions with the research team allowed the progression and development of data analysis, identifying and separating relevant discursive structures in the texts, capable of expanding the understanding of the autonomy of the older women. Thus, the categorization of elements with common characteristics was carried out, grouping elements, ideas or expressions around a concept.

Although different themes were found in the data analysis, this article only addresses the constitution of the institutionalized older women’s autonomy discourse. Soon after data collection, the importance of the research results was discussed with the LTCF manager at the time and with some participants. The results will be presented to the other participants and, dialogically, they will be able to allow reflections on the autonomy of the institutionalized older person in LTCFs.

According to the precepts of Resolution No. 466/2012, the project was approved by the Ethics and Research Committee of the Federal University of Minas Gerais, under Opinion N^o. 2.470.752/2018. The confidentiality of information and the identity of the participants was maintained. Thus, the professionals were identified in the research results by the letter P and the older women by the letter I and numbered according to the sequence of interviews. All participants signed the Informed Consent Form.

RESULTS

Data analysis showed that, although professionals report respecting the wishes of the older women, institutional routines, in a way, define and naturalize the behavior of residents in the institution.

“If you sit her down watching a program, then she will stay. Unless she starts to bother you, that is, something that wasn’t her habit or she doesn’t like it. She will signal and we will withdraw her from that environment. But most follow the institutional routine without complaining, without considering, because they’re used to being that way” (P4). “[...] I have breakfast before tidying my room. I have breakfast, clean the room, take a shower [...]” (I2).

The LTCF is a place of routines, where activities are repeated day after day. Every day, dependent older women are grouped in certain environments, such as the TV room or the area close to the cafeteria. The times in common environments are predetermined, thus establishing control over the use of spaces, which creates a pattern of behavior and allows for better knowledge of the location of the older women:

“Of course, being an institution, there are routines, right?! At home, you can see that most older women do not stay in bed. Unless they’re feeling indisposed, right?!” (P12). “Look, my daily life here is twenty-four hours in bed, because I had thrombosis in my right leg [...] my daily life is in bed.” (I5)

The times for most daily activities are well defined. The older women should be ready for breakfast at 7:30 am, so showers start at 6 am. From 8 am to 10 am they watch TV, lunch is served at 11 am, in the afternoon they watch TV again and, finally, dinner is served at 5 pm. The daily routine ends at 6 pm, when the older women, especially dependents, are placed in their beds to sleep.

The visits to the institution took place between January and March, the vacation period for students who carry out activities there. Among them are physiotherapy, medical research, a group of singers and clowns, classes with a physical educator. However, during this period, the place was quieter and more empty, which highlighted the routine of everyday life.

“Well, there’s a time for everything here! Everything! [...] when the soap opera is almost finished, I’m already making the bed to sleep [...] when it comes to dinner for the residents at 5 pm, I go down and get some soup or milk to drink at night” (I2).

In this context of such well-established routines, there is little room for decision-making by the older women. Their autonomy is forgotten in routines that, in a way, hide their desires, their choices and their own freedom, as the professional points out:

“Is it possible, one day, for one not to want a certain food and to eat another food? Yes, it’s possible! So, while this is not a problem for us, we will do it. It will be a problem the day that several... have different desires. Then, I think it homogenizes it, there is no way. In collectivity you can’t think about each one all the time...” (P7).

The professional’s discourse points to the Institution’s limited flexibility in relation to the particular wishes of the older women, recognizing the supremacy of the collectivity over individuality. However, even in the face of a list of rules and norms established in the daily life of the LTCF, obedience to them is not always perceived by the older women as a form of curtailing their autonomy.

“I don’t really like going out, no. But if I want to, I decide I want to go: “Sister, I want to go to such a place. Can I?” “You can.” And I will, got it!? So, like that, we have freedom, you know?” (I3). “[...] there are things we have to [...] talk to the coordinator! What are you going to do and such, right?! But, for me, the decision, I know how to make. But, as I live here, then, we have to obey, right?! To render account” (I4).

The discourse shows that the power of the norm and regulation is exercised over them, leading them to submit to the established rules. In addition, the older women have their lives determined by institutional norms according to their degree of dependence:

“There are older women who like to take a shower at 4 am, 5 am, but there are older women who want to take a shower more throughout the day. If she is independent, she has no problem, but if she depends on the caregivers, she will have up to 9 o’clock to take a shower” (P12). “In every social group there must be norms and limits. So, then, we can’t give this full right of choice, can we?! So, some have all the independence they want, we don’t arrest them or anything. But others don’t. So, it is the minority that has their independence and autonomy” (P11). “I think it’s great, you know, because if I had been so dependent, I don’t think it would be that good, lol” (I3).

It is also observed that the autonomy of older women is put into question according to intellectual and cognitive limitations that prevent them from managing their own finances and their lives:

“They don’t have any autonomy. They are thus totally knowledgeless and lay. Many are illiterate [...] There is one with a mental disability. There is already a part of their intellectual... so compromised. They have no management. They don’t know, they can’t manage the financial part.” (P8)

However, it is worth considering that, not always, submission to the rules takes place in a passive way, raising a subtle expression of resistance to institutional rules, certain attempts to escape the established control:

“[...] she really likes standing there at the edge of the gate. Then you go with patience: “So and so, let’s go!” And she goes: “No!” Then there are times that, or it goes in a spurt, “Let’s go!” or, if not, you have to come and say really angry “So-and-so, let’s get out of there?!” (P2). “So it gets a little bit painful, when they get here, it’s hard to adapt, right?! They keep wanting to leave, wanting to run away.” (I3)

The speeches show a form of resistance of the older women to institutional norms. The desire to run away or to see people walking in the streets, or even the desire to see life outside the Institution’s walls, makes her stay close to the gate in the expectation that an opportunity to escape will arise.

DISCUSSION

Autonomy is defined as the right to make decisions, think, decide and act, in view of one’s own beliefs and values, based on what is believed to be the best for oneself²⁰. In institutions, in general, it is challenging for the team to promote the autonomy of the older person. Professional paternalism, when the professional starts to make decisions for the older person in order to benefit them, is one of the attitudes that can compromise the autonomy of the institutionalized person²¹.

A study carried out with nurses on the perception of the older person’s autonomy at the end of life showed that, for professionals, older people have the right to autonomy, including the power to decide about their life, however, this autonomy can be conditioned to certain factors , such as diseases and level of cognition to make decisions²². In addition, professionals mistakenly relate childhood to old age, disregarding the entire life story of the older person, as if they were not competent to manage it²¹.

In doing so, they use the institution’s disciplinary norms and rules as a means of superimposing their truths on those of the older people.

The disciplinary power, in the institutional context, acts silently and subtly, training bodies so that they become docile¹⁷. If, on the one hand, autonomy is exercised within spatial boundaries, discipline is exercised over the bodies of individuals, with the power to affect subjects capable of voluntary actions²³. At the LTCF, through hierarchical power relations, norms are established with a view to serving the community to ensure the continuity of the daily work dynamics. Although these norms are not designed with the intention of restricting the individual autonomy of the older women, they end up delineating their decision-making limit. Thus, an institutionalization model is formed that is loaded with control, discipline, division and homogenization²³.

The countless rules and routines homogenize life, in a daily routine in which discipline prevails, with control over the lives of the older women and the consequent decrease in their autonomy²⁴. Independent older women are confined to their rooms or, with consent, can leave the LTCF, while dependente ones stay in the television rooms on their respective dormitory floors. Although the independent older women have the possibility of choice, they also end up adapting to the norms and their autonomy is forgotten inside each room.

Homogenizing the daily lives of the older women makes the organization of demands for caregivers less complex, reducing the space for will and desire. In this sense, it is important to consider that behaviors that really increase the subjects’ autonomy are based on meaningful choices for them, which involves questioning the other about trivial issues and paying attention to small details²⁴.

In a study carried out in Mexico with more than a thousand older people, with the aim of evaluating the perception of the older people themselves about their autonomy, it was identified that even older people with cognitive impairment can coherently answer questions about preferences, choices and their participation in decisions about daily life, providing accurate and reliable information. The results also indicated that cognitive impairment is associated with a low perception of autonomy, which can lead to high levels of anxiety, depression and loss of independence²⁵.

During the research data collection, the LTCF regiment was in the final phase of elaboration by the coordination, together with the care team. However, even though, at that time, there was no formal regulation of institutional norms, the rules and routines were implicitly placed, being known to both residents and professionals.

On the other hand, it is clear that, from the perspective of professionals, the autonomy of older women is not always recognized, due to the fact that they no longer have management and knowledge. Power produces knowledge and vice-versa, with the power/knowledge binomial being directly related, so that there is no power relationship without the parallel of a field of knowledge, nor knowledge that does not constitute power relations²³. The team’s power over the older women’s daily lives was incorporated in the organization, being institutionalized in the predominant structures and constantly recaptured²⁶.

Finally, it should be noted that for every exercise of power, there is, on the other hand, the cost to be paid for it, that is, a resistance to the instituted power. The institutional space, due to its countless rules, routines, hierarchical relationships, with consequent restriction of autonomy, provokes expressions of resistance represented by dissatisfaction, disagreement and invention of their own and imaginary spaces. In this context, the subject finds his subjectivation possibilities and builds resistance or subversion strategies to the social orders that limit them, which are represented by acts of freedom²⁷. The older women’s resistance strategies occur during times of escape, which made the institution install gates and cameras everywhere.

Among the limitations of the research, the fact that it was carried out in only one LTCF stands out. However, it is expected that this study can contribute to the reflection of a dignified old age, as older people continue to be segregated and excluded from living in the society. The asylum logic is maintained, instead of inserting them into the community and making them active and autonomous.

Thus, it emphasizes the importance and need for new studies that broaden the view on the autonomy of institutionalized older people and encompass the perspective of more heterogeneous groups.

CONCLUSION

The research results indicate that, for a proper functioning of the structure composed of different people who reside and work in this environment, limits and rules are necessary. However, despite the LTCF being an institution governed by norms, it is important to consider that norms are not primarily used as an instrument for controlling and restricting the decision-making exercise of older women.

The epidemiological transition has accelerated the transformation of society’s relationship with the LTCFs, as well as requiring these institutions to change their daily practices. The ideology, physical structure and organization of the environment of an LTCF, as well as professional practice, work as a plot that reinforces dependence and undermines the autonomy of the older person, emerging from the discourses of professionals and older women.

However, it is necessary to advance more with regard to specific public policies for LTCFs, with a clear definition of their role and guidelines for a qualified practice. The financing of LTCFs also deserves attention from the public authorities, so that it is possible to enable their proper functioning, physical structure capable of meeting the demands of the older person, as well as providing a properly qualified professional body.

There is still limited knowledge about these practices and their effects on the lives of older people who live the reality of institutionalization, including with regard to their autonomy. Thus, it is expected that this study can contribute to reflections on issues involving the maintenance and expansion of the older person’s autonomy in the institutional routine.

• No funding was received in relation to the present study.

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Edited by

Edited by: Marquiony Marques dos Santos

Publication Dates

• Publication in this collection
  01 Oct 2021
• Date of issue
  2021

History

• Received
  22 Nov 2020
• Accepted
  16 Aug 2021