Reflections on elderly autonomy and its meaning for the practice of nursing care

Rev Bras Enferm. 2021;74(3): e20200723 https://doi.org/10.1590/0034-7167-2020-0723 5 of ABSTRACT Objective: To reflect on autonomy in health care, its perspective on the lives of the elderly, and its meaning for the practice of nursing care. Methods: Theoretical essay on the practice of nursing care to promote autonomy and self-care for the elderly. Results: It is necessary to qualify the practice of nursing care to consider the aging process and maintain the autonomy of the elderly. Three parts emerged: “The autonomy of the elderly and the care plan”, “Nursing in the self-care process”, and “Challenges to the practice of caring for the elderly in nursing”. Final considerations: There is still a deficiency in promoting autonomy for the elderly due to the need for a review of the practice of nursing care, which, considering aging in Brazil, needs to undertake new actions in order to encourage self-care and autonomy in this population. Descriptors: Nursing; Personal Autonomy; Elderly; Nursing Care; Self-Care.


INTRODUCTION
The world shows rapid aging in the population and consequent change in the structure of the population pyramid. In Brazil, according to data from the Instituto Brasileiro de Geografia e Estatística (IBGE) [Brazilian Institute of Geography and Statistics], the elderly population reached the 29 million mark in 2019. The forecast for 2060 is that the mark will be of 73 million people over the age of 60 (1) .
The improvement in socioeconomic development, the promotion of vaccination campaigns and greater access to health care are some of the factors that contributed to the establishment of this current reality. Elderly death occurs, predominantly, due to chronic non-communicable diseases (CNCDs), which include cardiovascular diseases, neoplasms, chronic respiratory diseases, and diabetes mellitus. Thus, the epidemiological transition followed the evolution of changes in the health-disease process, however, there was no adequate preparation of public health policies to deal with this new statistic (2) .
In this perspective, the situation tends to a more complex scenario for the elderly, given that the association of CNCDs alongside the natural physiological process of aging can result in functional impairment to different degrees. These factors have important implications in several areas, such as human relationships, daily activities, well-being, self-care, and personal autonomy. In view of the fact that the elderly are more affected by CNCDs, qualified nursing care that understands the magnitude and repercussions of all these factors on the individual's life is unquestionable (3) .
Furthermore, the difficult psycho-emotional confrontation in dealing with the aging process, along physiological changes during the illness, compound with other social challenges, such as the negative stigmatized image of the elderly in the collective ideal, which generates depersonification and whose influence interferes in the nurse-client relationship. The association between advancing age and disability compromises the development of a professional-patient shared care plan, which tends to become imposing and unilateral, with the possibility of depriving the elderly of the decision-making power over themselves, a fact that contributes to the perpetuation of a paternalistic care posture (3)(4) .
This whole context points to a complex situational dynamic that culminates in great damage to the elderly. The low integration and social receptivity, combined with the unpreparedness of health professionals in dealing with the issues of aging in a comprehensive manner, impose serious limitations to their wellbeing and satisfaction with life (3)(4)(5)(6) .
In this sense, the question is posed: "What is the importance of reflecting on the practice of nursing care with the promotion of elderly autonomy? How can the nursing practice add quality of life and social transformation to them?" The reasons are innumerable and crucial for the improvement of the planning of care in which the interaction between the peers prevails, above all, the active participation of the patient, considering that the projection for this population gains prominence and the inability to meet global biopsychosocial demands still compromise the care provided to it (4)(5) .
Within the scope of public policies, the National Health Policy for the Elderly was approved by Ordinance 2,528, of October 19, 2006, whose primary purpose is to recover, maintain, and promote the autonomy and independence of the elderly, ensuring their physical and moral integrity (7) . In other words, it is a plan that aims to promote active aging by encouraging personal autonomy and active participation in the various areas of their life.
In addition, article 42 of the Resolution of the Federal Council of Nursing No. 564/2017, includes as a professional duty for nursing professionals, the respect towards the right of the person or his/her legal representative to exercise autonomy (8) . However, in the understanding of nursing, this issue is beyond compliance with the law, since the damage caused to patients in the absence of the promotion of autonomy affects physical, emotional, psychological, and social spheres (3)(4)(5)(6) . Thus, this reflection addresses current and unavoidable issues in the field of public health and the provision of qualified and unique assistance services.
From a methodological point of view, we divided this reflection into three parts. In the first, entitled "The autonomy of the elderly and the care plan", we discussed the issue of autonomy in the lives of the elderly and its relationship with the elaboration of the care plan. In the second, "Nursing in the self-care process", we present considerations about the role of nursing in the process of developing self-care for the elderly. Finally, "Challenges to the practice of caring for the elderly in nursing", we address the challenges to the practice of nursing care in promoting the autonomy of the elderly.
Thus, the aim of this article is to reflect on health autonomy, its perspective on the lives of the elderly and its meaning for the practice of nursing care.

THE AUTONOMY OF THE ELDERLY AND THE CARE PLAN
The consequences of CNCDs greatly affect the quality of life of the elderly, directly impacting their autonomy and independence, given that the developments are mostly associated with some form of physical limitation, which compromises the activities of daily living and interpersonal relationship (4,9) .
The concept of autonomy can be understood as the right of an individual, who is free to choose among several alternatives presented, according to their beliefs, values, and wishes, and to make decisions freely, according to their judgment in a given situation, regardless of age (3)(4) .
Thus, the nursing team needs to have this parameter as a guiding principle when thinking about the care plan for the elderly with CNCDs in their daily practice, considering, in addition to the already mentioned prerogative imposed on the nursing practice, the problem involved in this reflection. The care plan is prepared based on the needs identified by the nursing professional, in order to promote health, paying attention to the person's wishes and thus enabling a relationship based on trust, which promotes adequate management of the chronic disease by the elderly, their family, and the health team together (5,9) .
However, it is known that the physiological changes of aging affect the recognition of the power of choice, in such a way that, commonly, the elderly are prevented from actively participating in the development of the care plan by the nursing team (4)(5) . This fact demonstrates that there is a dominance of scientific knowledge over the client's considerations and, when health professionals act to the detriment of the individual's participatory and decision-making capacity, this results in negative and profound impacts in the emotional, physical, and psychological of Reflections on elderly autonomy and its meaning for the practice of nursing care Samartini RS, Cândido VC.
spheres of the patient, in addition to reiterating the devaluation of the elderly's autonomy (3)(4)(5)(6) . Thus, care planning must be developed with the patient and aim at preserving health, active participation in treatment, promoting autonomy, and encouraging independence in daily activities (4)(5)9) . Aging in an environment that stimulates participation by health professionals is something that the elderly crave, and contributes in a forceful way with the feeling of satisfaction with life and self-control, with personal autonomy being the main responsible for these feelings (5)(6) .
That said, it is observed that the different demands for global health care require a dialogue based on respect for the elderly, in order to create a mutual relationship of trust and, with that, a planning in which there is the sharing of care strategies and decisions that includes both the necessary technical care and the client's preferences (5,9) . This professional posture increases the patient's knowledge of clinical conditions and favors access to information. In other words, it allows the elderly to have greater understanding about themselves, which gives them a basis to participate in discussions, empowering them to actively engage in issues relevant to their health and encouraging them to express their preferences, priorities, and values (4)(5) .
An important point is also that there can often be differences in values and beliefs between professional and client. In this situation, the nurse must have the ability to deal with these diversities, and the care plan must be explained and discussed, so that the elderly feel respected in their considerations (9) .
The aging process is complex and multidimensional, so it is essential that the nursing team seeks to have a technical authority and is prepared to understand and deal with the specificities of this stage of life (9) .
In this sense, when the health professional understands and sensitizes his/her view towards the elderly, his/her responsibility in recognizing that person as autonomous and having his/her own voice that needs to be heard becomes permanent (5) . The art of nursing practice, largely due to its humanistic and philosophical training, is in the competence of seeing the individual beyond his primary functionalities and needs, and with this, it has full potential to generate great transformations in human relationships. The professional, by stimulating and valuing the autonomy of an elderly person identified with low participatory power, causes a series of effects, as the result of this action will not be limited only to the care of his health (4,9) . The nurse who apprehends this conduct restores the elderly's power of speech and the power of choice, as well as allows them to rediscover themselves in their potentials and assume their identity, recognizing themselves as their own, demanding space for speech and taking ownership of their rights. It is a social transformation in which nursing must take an active role.
The central point on which this theme allows us to reflect is that aging in a healthy and autonomous way is essential to ensure dignity, psycho-emotional well-being, and quality of life, thus allowing the elderly to express themselves fully as an individual (3,5,9) .
In this way, personal autonomy assumes a fundamental and essential aspect in the healthy aging process, as it gives the possibility of achieving a full and happy way of living, according to individual limits (3,(5)(6) . The promotion of autonomy and the guarantee of this right in nursing care is an important step in the direction of social transformation, guaranteeing a more dignified life for the elderly within society (4) .

NURSING IN THE SELF-CARE PROCESS
The theory of deficit in nursing self-care was developed by the American nurse Dorothea Orem, whose definition upholds the practice of activities that aim to maintain life, health, and well-being. For this theory, nursing care is established when individuals are unable to perform health care due to some limitation or insecurity (10) . For the aforementioned theorist, self-care is a human regulatory function, which allows nurses to offer care guidelines that aim to increase the patient's knowledge and skills, contributing to the promotion of autonomy and independence to carry out their activities (10) .
The instrumentalization of the elderly in the management of self-care improves the recovery of health levels and, consequently, the feeling of independence and control of life itself. With this, the theory offers conceptual elements for the practice of care, in such a way that the nursing professional has subsidies to elaborate an adequate plan aimed at personal needs, respecting the individualities and limitations of each person (9,11) .
The elderly need to be stimulated and encouraged as to the exercise of self-care and, with this, be able to create a self-management that satisfies their needs. This stimulus, when adopted by the nursing team, values the patient's active participation, since the assertive orientations about their demands and how self-care should be practiced enable the exchange of knowledge and, mainly, provide autonomy within certain levels of possibility (5,9,11) .
This dynamic contributes in reducing the feeling of limitation and insecurity in health-related actions, in addition to leading to better acceptance of the aging process and the necessary adaptations for a good living with chronic diseases, generating positive feelings that are fundamental to strengthen self-confidence, autonomy, and quality of life (5)(6)9) .
Often, the relationship between patient and disease is, for the elderly, physically and mentally draining due to little understanding of the necessary adaptations in lifestyle and the treatment that chronic diseases require. The change in this relationship is also an important point that the practice of self-care provides since it helps the individual to reframe their health condition (9) . In this respect, the improvement of self-esteem and self-confidence in dealing with the disease and taking care of oneself has repercussions in the personal and social spheres, as it collaborates with the upkeep of human relationships within social life (5)(6) .
Therefore, a close relationship between the instrumentalization for the exercise of self-care for the elderly with a deficit in care self-management and the promotion of personal autonomy is observed, as instrumentalizing them to act and take care of themselves confirms the right of the decision-making power that they have over themselves, customizing the care according to their values and preferences (9,11) .
Additionally, the role of nursing is crucial for the elderly to actualize these achievements. The promotion of health education with a focus on the specific needs of this public must be guided by technical-scientific knowledge and patient-centered communication, with guidance and support for necessary adaptations (9) . With this, the health professional creates favorable conditions for of Reflections on elderly autonomy and its meaning for the practice of nursing care Samartini RS, Cândido VC. the development, in the elderly, of specific skills and knowledge about their condition through educational actions (5,9) . Thus, the application of this theory is supported on a theoretical basis with scientific rigor, which must be reinforced regarding the practice of nursing care. The care approach should aim, above all, at improving the patient's life and health conditions to generate feelings of security and well-being (6,9,11) .

CHALLENGES TO THE PRACTICE OF ELDERLY NURSING CARE
The aging process is directly impacted by people's lifestyles, which can be affected early by CNCDs (2) . As soon as the modus operandi of a society changes, the approach to health care needs to be updated and shaped, respecting the technical-scientific parameters. Considering this, new questions on the challenges for caring for the elderly performed by the nursing team arise in order to contemplate the new biopsychosocial demands (4,9) .
The paternalistic culture in the practice of nursing care is also a challenge that requires some reflection, since this conduct establishes barriers in the exercise of personal autonomy and generates incompatibility between the patient's desires and the imposed treatment (3)(4) . Failure to recognize this posture generates great harm to the elderly regarding the possibility of strengthening autonomy and independence to exercise self-care (4)(5) . In this context, it is reasonable that nursing professionals are sensitized regarding the perspective of health and well-being of the elderly, as well as the impact that the lack of participation in the care plan choices and decisions has on these people's lives (4)(5)9) . Therefore, it must be considered that the association between the biological and social context makes it difficult to understand the complex processes that emerge from aging (3) . This scenario is evident, above all, in the unpreparedness of nursing professionals in dealing with the need for comprehensive care of the demands of the elderly. Thus, the lack of specific knowledge on the proper management of comorbidities in the elderly culminates in a predominantly flawed and fragmented care plan (3)(4)(5)9) .
Furthermore, the practice of nursing care needs to be based on a relationship of trust with the client; and, for that, the establishment of a patient-centered communication with a careful listening to their desires, fears, difficulties, and expectations contributes to strengthen this relationship (4) . The construction of this bond, in addition to offering subsidies for a personalized care plan, result in a deeper respect for individualities, in promoting the autonomy and independence of the elderly. However, for this relationship to be built, it is first necessary to overcome the social stigmas and paternalistic attitudes that interfere with the real understanding of personal demands and preferences (3)(4) .
The art of caring has its own challenges, given that each person has biopsychosocial characteristics that shape us in a particular way, causing different perspectives on the understandings of life, interpretations, and responses of the health-disease process. In other words, all this dynamic and complex intrapersonal relationship influences care planning within the scope of an interpersonal nurse-client relationship, as it is permeated with the values and beliefs of each party (4,9) .
However, the question remains to what extent the practice of nursing care brings new meanings to the life of the elderly? How can this generate permanent impacts on their life? The reinterpretation of the negative social image and moral values attributed to aging in society is also associated with the social function of nursing, since health education with a view to valuing the elderly, promoting active and healthy aging, as well as preventing disease also has the power to generate positive results in the integration of the elderly into the social circle. These educational actions have equally important results in the short and long term: in the first, pertaining to the effects of comprehensive care on the quality of life and well-being of the elderly; in the second, regarding the acceptability of the elderly in the participatory context of society (3)(4)(5)9) .
Thus, it is worth noting that the scope of the nurse's performance goes beyond the purely biological, having a crucial role in respect for human dignity.

FINAL CONSIDERATIONS
If, on the one hand, the increase in the incidence of CNCDs implies damage to autonomy and self-care, compromising the quality of life and well-being, on the other hand, social stigmas favor the depersonification of the elderly, generating dependency and annulment of their identity before society.
Therefore, it is an emerging theme this reflection on the autonomy of the elderly and its meaning in the practice of nursing care, since there is still a resistance in the accepting of a care plan with shared information, even though there are legal bearings that support this right. To the nursing team, lies the responsibility of verifying possible barriers that prevent the elderly from exercising their autonomy, as well as defending them in daily clinical practice as a mechanism for consolidating this right.
Therefore, nursing care must include actions that foster, support, and encourage the exercise of autonomy and the management of self-care for the elderly. The care plan must be carried out based on technical-scientific knowledge and must be performed as a group through patient-centered communication for better decision-making. This posture demonstrates, above all, the professional commitment of nurses towards a healthier and more dignified aging and is fundamental for maintaining quality of life.
It is essential that nursing professionals be qualified in terms of understanding the complex aging process, as well as the particularities that an elderly patient with a CNCD has. Educational actions should be aimed at promoting health and autonomy, active aging, and maintaining quality of life. of