Gerontological contributions to the care of elderly people in long-term care facilities

Objective: To analyze Brazilian scientifi c productions from the last 11 years which show the contributions of nursing to elderly people in long-term care facilities. Method: This is an integrative literature review. The search took place in the Virtual Health Library (VHL) in the BDENF and LILACS databases and the SCIELO virtual library, between June and October 2016, using the keyword longterm care facility and the descriptors nursing and geriatrics. Results: Eleven studies were selected, published 2005 and 2016, with various methodological approaches that enabled discussion of the proposed objective. Conclusion: The contributions of nursing to institutionalized elderly people were linked to health promotion measures, as well as simple interventions, such as listening, interacting, offering recreation and helping in psychoaffective relationships. These activities contributed to raising the self-esteem of the individuals. Descriptors: Nursing; Geriatrics; Homes for the Aged; Nursing Care; Review Literature as Topic. RESUMO Objetivo: analisar produções científi cas brasileiras dos últimos onze anos que demonstram as contribuições da Enfermagem aos idosos em instituições de longa permanência. Método: trata-se de uma revisão integrativa de literatura. A busca ocorreu na biblioteca virtual da saúde (BVS), nas bases BDENF, LILACS e na biblioteca virtual SCIELO, entre junho e outubro de 2016, utilizando-se as palavras-chave Instituição de Longa Permanência e os descritores enfermagem e geriatria. Resultados: foram selecionados 11 estudos publicados entre 2005 e 2016, com diversas abordagens metodológicas que permitiram a discussão do objetivo proposto. Conclusão: as contribuições da enfermagem ao idoso institucionalizado encontram-se atreladas às medidas de promoção à saúde, bem como às intervenções simples, como ouvir, interagir, ofertar entretenimento e ajudar nas relações psicoafetivas, sendo que essas condutas contribuem para o aumento da autoestima do indivíduo. Descritores: Enfermagem; Geriatria; Instituição de Longa Permanência para Idosos; Cuidados de Enfermagem; Literatura de Revisão como Assunto. RESUMEN Objetivo: Analizar producciones científi cas brasileñas de los últimos once años que demuestran las contribuciones de enfermería a los ancianos en hogares para ancianos. Método: Revisión integrativa de literatura. Búsqueda realizada en Biblioteca Virtual de Salud (BVS), en las bases BDENF, LILACS y en la biblioteca virtual SCIELO, entre junio y octubre de 2016, utilizando las palabras clave Hogares para Ancianos y los descriptores enfermería y geriatría. Resultados: Fueron seleccionados 11 estudios publicados entre 2005 y 2016, con diversos abordajes metodológicos que permitieron discutir el objetivo propuesto. Conclusión: Las contribuciones de Enfermería al anciano institucionalizado están sujetas a las medidas de promoción de salud, así como a las intervenciones simples, como oír, interactuar, ofrecer entretenimiento y ayudar en las relaciones psicoafectivas, siendo que dichas conductas permiten el aumento de la autoestima del individuo. Descriptores: Enfermería; Geriatría; Hogares para Ancianos; Atención de Enfermería; Literatura de Revisión como Asunto. Gerontological contributions to the care of elderly people in long-term care facilities Contribuições gerontológicas para assistência de idosos em instituição de longa permanência Contribuciones gerontológicas para la atención de personas mayores en hogares para ancianos REVIEW Rose Mary Costa Rosa Andrade Silva E-mail: roserosauff@gmail.com CORRESPONDING AUTHOR


INTRODUCTION
The topic of elderly people is currently one of the most discussed topics worldwide.It has been noted, in various studies, that this subject is already a major one in Brazil, given that according to the World Health Organization (WHO) there will be two billion elderly people in the world by 2050 and, in 2025, Brazil will be the country with the sixth largest elderly population (1) .Although studies demonstrate that this process has been underway for decades, it was only after the international conference in 1982 that Brazil started tuning into gerontological thought (2) .
The approval of the National Policy for the Elderly (PNI, in Portuguese) (3) in 1994 and Decree No. 1948 which regulates Law No. 8842 (3) , of January 4, 1994, that rules on the National Policy for the Elderly and establishes other provisions, seeks to ensure social rights that guarantee the promotion of autonomy, integration and effective participation of the elderly in society, so that they can exercise their citizenship (3) .However, in February 2006, through the enactment of Ordinance No. 399/GM (3) , which introduced the Pact for Health consolidated by the Brazilian unified health system (SUS, in Portuguese) and approved the operational guidelines of this pact, elderly people were integrated into the Pact for Health Guidelines documents, which includes the Pact for Life.The health of this population became one of the six priorities agreed on by the three spheres of government.A series of actions was presented aimed at implementing some of the guidelines from the National Elderly Healthcare Policy.
In view of the fact that aging is considered a "problem", and not an achievement, and that the elderly are often viewed by their families as a "burden" and by society and governments as a "duty" (4) , even after the implementation of policies meant to protect this population, studies that focus on longterm care facilities are needed.This is because many families opt to place their elderly relatives in these facilities, even though the Brazilian Federal Constitution of 1988, in Articles 229 and 230, urges families to assist their loved ones in old age (5) .
In light of this, it can be seen that generally, after 60 years of age and/or in the case of chronic diseases, long-term care facilities for the elderly are increasingly sought, where families endeavor to ensure the well-being, professional care, and comfort of family members who, in their view, have become dependent upon care (6) .Within this context, gerontological nurses play a very important role in elderly care, since they are qualified to identify the particularities that occur as a result of the aging process.They also seek to involve the family in the care process and work together with other professionals to resolve health problems (7) .
The present study is relevant since it strives for aging to occur in a healthy and active way.It seeks to encourage elderly people to be independent and care for themselves, as well as enable nursing to meet these needs when such independence is no longer possible, due to motor aging which obliges older people to modify their interaction with themselves, other people and the world (8) .

OBJECTIVE
Analyze Brazilian scientific productions from the last 11 years that show the contributions of nursing to elderly people in long-term care facilities.

Ethical aspects
Since this was an integrative literature review, the study was not submitted to a research ethics committee, but the ideas of the authors of the publications used in the development of this study were maintained.

Study type
The methodology used for this study was an integrative literature review, since it enables a combination of data from empirical and theoretical literature that can be directed toward the definition of concepts, identification of gaps in study areas, review of theories, and a methodological analysis of studies on a certain topic, permitting an analysis of the literature (9) .This integrative literature review was conducted through a research protocol based on six steps: identification of the topic and selection of the research question, establishment of inclusion and exclusion criteria for the sample selection, identification of the preselected and selected studies, categorization, analysis and interpretation of the results, and presentation of the review (10) .
The study was based on the following research question: What are the contributions of Brazilian gerontological nursing to elderly people in long-term care facilities?

Data source
To select the articles, the Virtual Health Library was used, which provides accesses to the databases of the BDENF (Nursing Database); LILACS (Latin American and Caribbean Literature in Health Sciences), and the virtual library SCIELO (Scientific Electronic Library Online).

Data collection and organization
The search strategy entailed the use of keywords and descriptors connected through the Boolean operator "AND".
The keyword used was "long-term care facility" and the descriptors pertaining to the theme were "nursing" and "geriatrics", identified through the DeCS.The articles selected were in Portuguese.
The inclusion criteria for selecting the articles were: articles of various methodologies, published in Portuguese, available in full and for free on the selected portals, published between 2005 and 2016, that dealt with the theme.The inclusion criterion that articles are provided for free on the selected portals was based on the premise that free access to scientific productions facilitates the search for and reading and dissemination of productions by professionals working in the health field.It was also decided not to exclude review studies, on the grounds that methodological issues should not be used as an inclusion criterion, because such a criterion could generate problems in the results if the reviewer were to consider a certain methodological approach inadequate and, in view of this, exclude studies (10) .
It was decided to use the time period of 2005 to 2016, since in 2005 the scientific results of studies related to the enactment of the statute of the elderly (in 2003) started being disseminated.This enabled the authors to identify mentions of the theme in question, based on the main care options described in this law for elderly people.On September 26, 2005, the technical regulations of AN-VISA No. 283 were also released, which define the operational norms for long-term care facilities for the elderly, which promoted discussion of the proposed objectives.The time period was extended to 2016 to show the results related to the contributions of nursing to elderly people in long-term care facilities, after a little more than a decade.
The exclusion criteria were: scientific productions that only contained an abstract or those that were indexed in more than one database.The research was conducted from June to October 2016.

Data analysis
After identifying the preselected studies (n=15), the titles of the publications, abstracts, and descriptors were read by two independent reviewers to determine if they corresponded to the theme and should be included in the review (Figure 1).Following this, they were read in full, in order to perform the characterization, analysis and interpretation of the results, and presentation of the review.
The reading of the studies to check the preselected material led to the exclusion of four publications since they were duplicated in the databases (LILACS: n=2) or did not correspond to the theme due to dealing with care in a hospital system (BDENF: n=2).The following flowchart describes the methodological path used for identifying the studies included in the review (Figure 1).Then, the data related to the methodological characteristics of the articles selected was summarized, and the findings were presented in the results.

RESULTS
The data was organized based on the analysis, in full, of the selected articles, and a collection instrument was created to characterize the articles found according to the following aspects: title, year, region, journal, keywords/descriptors, objective, contribution of the study and conclusions, as shown in charts 1 and 2. Ilha S, Argenta C, Silva MRS, Vaz MRC, Pelzer MT, Backes DS (11) Active aging: necessary reflections for nurse/health professionals 2016 Rio de Janeiro Revista Online de Pesquisa Elderly health; Longevity; Quality of life; Nursing Guimarães DBO, Figueiredo MLF, Castro L, Vieira S (1) Teaching gerontogeriatric-geriatric undergraduate: a reflection on contributions and implications for nursing 2013 Piauí Revista de Enfermagem Education; Elderly people; Nursing Bentes ACO, Pedroso JS, Maciel CAB (12) The elderly in long-stay institutions: a bibliographic review.2012

Rio Grande do Sul Aletheia
Elderly people; Institutionalization; Quality of life Search for publications through the keyword and descriptors and the Boolean operator "AND".(n=3,165) SCIELO: 1,157 / LILACS: 1,201 / BDENF: 807 To fine tune the search, the keyword "long-term care facility" and the descriptor "geriatrics" were joined through the Boolean operator "AND" (n=77).SCIELO: 43 / LILACS: 28 / BDENF: 6 Duplicate studies in the databases (n=247) Studies included in the review after being read in full (n=11) SCIELO: 3 / LILACS: 6 / BDENF: 2 Reading of the titles of the publications, abstracts and descriptors, by two reviewers, to determine the pertinence for inclusion or not in the study After rereading the titles, the keyword "long-term care facility" and the descriptors "geriatrics" and "nursing" were joined through the Boolean operator "AND" (n=15).

Figure 1 -Flowchart describing the methodological path for the results
To be continued Chart 2 -Characterization of the studies in terms of objective, contribution, and conclusion

Objective Contribution of the study Conclusion
Reflect on the possible factors that contribute to active aging, and on strategies that can be used by nurses and other health professionals to promote active aging (11) Reflections on the contributions of nursing to aging Intervention strategies need to be developed to modify the current configuration that based on curative and rehabilitation actions instead of health promotion for healthy aging.
The objective was to perform a critical analysis in relation to gerontological and geriatric education (1) Help prepare specific health professionals to care for elderly people The purpose of this study was to alert nursing professionals, students, and professors to the difficulties and challenges that exist in the area of elderly health, which, in addition to influencing teaching, enable a better understanding of the work environments, attitudes of professionals and options for improving the performance of these professionals.
Address the topic of elderly people in long-term care facilities in relation to successful aging and quality of life (12) Present evidence of successful aging in longterm care facilities (LTCF) Institutionalization is an issue that has generated extensive discussion.On the one hand, long-term care facilities whose purpose is to protect and care for the elderly, and on the other, elderly people facing new adaptations, both experience moments of transitoriness that also require recognition of their demands and needs.Although long-term care facilities for the elderly are typically care-based, there is a major movement to transform this paradigm in a positive way to make them welcoming environments conducive to new starts in life.
Assess the contribution of the use of significant resources during free times, for changes in the lifestyle of elderly people residing in longterm care facilities (13) Presentation of nontechnical or technological models for health promotion e role of nurses in the seniors '

DISCUSSION
When selecting the potential articles and reading them in full, the data was characterized, at which time the similarities between the selected materials were taken into consideration.As a result, the following four categories emerged that enabled discussion of the main topic: "Learning in order to care and understanding in order contribute"; "Elderly and longterm care facilities: the pursuit of care"; "Time versus elderly people: recovery of values"; and "Active aging and the nursing perspective".
Learning in order to care and understanding in order to contribute During the development of this category, it was noted that although there are policies and statutes that focus on the elderly, greater emphasis needs to be placed on gerontology and geriatrics in the training of professionals, in order to promote elderly health more efficiently and effectively (1,3) .
In this context, nursing professionals are seen as a link between family, government and society, since they apply technical and scientific knowledge according to the needs and complexities of each individual receiving care, but are also care professionals who understand and, above all, respect the other, regardless of any circumstances.It is expected that these professionals, as they carry out activities, such as ongoing education, will be mindful not only of knowledge transmission, but also the qualification of gerontological and geriatric care, in view of increased life expectancy.
Increased life expectancy has been due to technological advances, nutritional improvements and health promotion in developed and developing countries (14) , but parallel to this increase there are chronic disease care needs.
In light of this process, public policies need to ensure active aging, where functional capacity can be preserved as much as possible, so that elderly people can independently exercise their functions in society.
Another point worth noting is the occurrence of depression and frailty during institutionalization.These conditions should

Objective Contribution of the study Conclusion
Enhance the quality of life of elderly people (14) Educational actions that help provide better care Health promotion is essential for active aging and proposes the existence of a relationship between culture and health, favoring the acquisition of knowledge of nursing actions, with an emphasis on the interpersonal relationship between nurses and the elderly, based on communication and ethical principles.
Understand the nursing expectations of elderly people in basic care and indicate the needs of the elderly in this context (15) Care based on listening to the other, as opposed to only investing in techniques Nursing activities with elderly people within the context of basic care involve ongoing dialogue, since it is an intersubjective experience, i.e., the central focus is people -elderly people and nursing professionals.Therefore, an understanding attitude on the part of nurses is essential for promoting the well-being and health of elderly people, since the latter experience satisfaction when receiving care from people who show their human side.
Reflect on the necessary humanization of elderly care practices, as well as the training of formal caregivers and the urgent readaptation of the organizational structures of facilities that provide care and support to elderly people and their family members (16) Perception of the humanization of care given to elderly people It is necessary to insert other dimensions of values and attitudes to enrich the vision for elderly care in long-term care facilities, in order to achieve more beneficial results that represent, in a unique way, what elderly people are entitled to as human beings.
Surveillance of the health of the elderly and follow-up should be continuous, combining specific professional knowledge of geriatrics/gerontology and the beliefs commonly held by the elderly.
Identify the role of nurses in longterm care facilities for the elderly 17) Clarify the role of nurses and teams in long-term care facilities for the elderly It is important that the competent bodies that monitor nursing laws, at the national and international level, seek to guarantee the full involvement of nurses in long-term care facilities for the elderly, providing them a new field of action and ensuring better performance of activities by nursing workers.
Describe and assess the National Policy for the Elderly in Brazil and its relationship with nursing (3) Clarifications on laws and decrees for the elderly The study highlights nursing principles for ensuring the rights of the elderly, as well as the effective participation of nurses in nursing education improvements.
Based on the premise that understanding the mindset of the elderly toward aging will provide nursing knowledge for their care, investigate this from a socio-poetic perspective, together with elderly people (8) Understand aging and provide better care The contribution of the study involves the proposal of a socio-poetic care model that validates the hypothesis defended in this work: understanding the mindset of the elderly by the research group reveals the process of acceptance or denial of old age, demonstrating that people, in the continuity of life, do not want to be old (undesirable), but rather become elderly (age with well-being).
Reflect on the meaning of care of hospitalized elderly in the reality of nursing (2) Present ways of caring that surpass technology, at times when caring extends beyond curing This study concludes that nursing care actions encompass the acts and attitudes of the person-nurse, which are delineated by experiences and values over the course of life.
Chart 2 (concluded) be examined among institutionalized elderly people, since frailty may be a factor that leads to these individuals being admitted to facilities, in addition to being associated with falls.Depression rates were 95%, similar to the occurrence of frailty (18) .With respect to frailty, geriatric nurses testify to the importance of discussing the prognosis of elderly people in order to assist and improve decisions made in relation to institutionalized individuals (19) .Nursing works with evidence-based practices aimed at independence and autonomy and restoring the self-esteem of elderly people (in long-term care facility environments).It also seeks to promote health and prevent complications resulting from the aging process, through methods and strategies that are conducive to active aging in an ethical way, regardless of religious beliefs and free from prejudices on the part of professionals (14) .
Elderly people and long-term care facilities: the pursuit of care The care model that prevails in long-term care facilities for the elderly, whether affected or not by physical and physiological impairments, seeks to boost independence, preserve self-esteem and respect the individuality of the person receiving care.Although elderly people n may abruptly change from living at home to being in a care facility with rules and norms, living with other people in the same age range may be advantageous in the mid-term, due to the entire physical and professional infrastructure specially designed for them.However, for them to perceive these benefits, their arrival to the facility needs to be harmonious and they must be welcomed by gerontologists who are trained to understand this time of transition and can help them understand their new environment (12,17) .
Long-term care facilities are only inserted into the life of elderly people, or vice-versa, when their family members realize that they are unable, for some reason, to ensure the physical and mental well-being of their loved one (16) .Although the purpose of this type of institution is not to disassociate elderly people from their families, they feel this way when they are placed in this kind of facility, where the environment is initially strange, until new possibilities emerge, such as friendships and discovery of a new way of living.In this setting, nurses are equipped with all the technology to care for, strengthen and assist elderly people to adapt to other ways of staying healthy, even though removed from their daily family milieu.According to Heidegger and Mayerof (16) , care goes beyond performing actions for the other, but represents a possibility for engaging in relationships and learning from others, teaching and, especially, caring for and appreciating the value of others.

Time versus elderly people: recovery of values
The free time that elderly people have can help health professionals in health promotion activities.It is necessary to find productive activities for this public, such as handicraft workshops, dance classes, gardening or just taking care of their personal possessions (20) .Nursing can take advantage of these recreational times and implement activities that will benefit institutionalized elderly people.In addition, when they participate in activities such as dance, painting, bowling or bingo they become more attentive and willing to interact.
The introduction of activities aimed at fostering healthy behavior is essential for health improvement and management of chronic conditions.During these times, nurses can take advantage by supporting the initiation and maintenance of health behavior changes, since these changes which are based on health promotion, ultimately tend to favor the well-being of the individuals (21) and, consequently, their quality of life.Therefore, it is clear that the more prepared the nursing professional is, with regard to the implementation of health promotion activities, the easier it will be to make decisions beneficial to each individual (13) .
Nurses participate in care, whether technical or social, ethically assuming their role with dignity.This combination of attitudes is able to provide elderly people with a safe and comfortable environment, and maintain their physical and mental well-being.Therefore, nurses not only administer drugs and treatment, in addition to other procedures, but are often also a friend, assisting elderly people in this stage of life to face the battles inherent to being "old versus elderly".
The battle between being "old versus elderly" involves the dilemma of accepting or rejecting old age, tied to elderly people maintaining or losing their place in society.The perception that elderly people have throughout the aging process is related to society's outlook on them and the stereotypes it projects of them.The adoption of stereotypes related to the elderly leads these individuals to limit themselves to sectors in which their groups are not negatively stereotyped, which results in them losing their freedom to participate fully in society, and society loses the contributions that they could make to it. (22).Apart from loss of freedom due to social stereotypes, many elderly people also lose their freedom because of some form of dependence, which may be associated with the aging process.
During this stage, elderly people want this dependence to be seen as something temporary, able to be overcome and adaptable.This is when nursing professionals need to help them, so that they can use their potential to the maximum.Once elderly people realize that their chronological vision depends on them, they will feel more secure and confident, since they will understand that they have not become useless and are fully capable of producing and being useful through small tasks (workshops) individually planned for them (2,8) .Through the reorganization of their thoughts and ideas, their self-esteem and quality of life will achieve the goals planned by the team, and nurses will have successfully implemented care.

Active aging and the nursing perspective
According to the National Health Policy, aging does not mean being sick, but refers to decreased functional capacity, which modifies or affects quality of life.In order to restore the health of elderly people, gerontological nursing teams work together with interdisciplinary teams so that within the least time possible, the health of these individuals can be improved (3) .
In relation to the active aging process, physical, social, emotional, economic, cognitive and nutritional factors can be taken into consideration, to avoid risk factors that can impair the health of elderly people.Programs aimed at keeping older people active tend to be beneficial to physical, psychological and cognitive health.These are the three main aspects of health that must be preserved so that aging can occur in an active way, with preservation of social relationships, biobehavioral components and personality.These aspects can be used to guide specific actions for promotion of the health of elderly people (23) .
The development and practice of spirituality, "believing in God", help older people cope with the losses/transitions inherent to aging and also aids in preserving self-esteem, which results in positive behaviors (10) .Spirituality and religion play an important role in guiding and assisting elderly people in terms of finding meaning in their lives and coping with adverse situations.Many people see growing older as a period of spiritual growth and development, where spirituality and religion are a way to offset losses resulting from physical decline (24) Therefore, attitudes should be encouraged that are beneficial to elderly people and enable gerontological nursing to operate on the basis of these incentives, promoting care actions that encompass the psychoaffective needs of older people, since compassionate attitudes in the form of a look, gesture or simply listening tend to enhance the well-being of this population (10) .
The continuity of actions using soft technology helps gerontological nursing achieve its objective of improving the condition of elderly people, causing them to be protagonists of their own care and to seek independence, which improves their functional capacity and self-esteem.Therefore, when care needs to be collective, individual care will also be present, better understanding and drawing elderly people closer to nurses for one sole purpose: excellence of care (15) .

Limitations of study
A limitation to conducting the study were relevant gaps that still need to be filled by gerontological nursing, in terms of studies on elderly people who accept being placed in long-term care facilities by their families and elderly people who voluntarily seek to enter a long-term care facility.The technological and human progress in relation to active aging is striking, with gerontological nursing increasingly focused on providing specialized care to this unique and growing sector of the population.
Another limitation was the limited number of articles in national databases, since the objective of this study was based on Brazilian productions.This underscores the need to conduct further studies related to the work of nursing in long-term care facilities.This would expand the archive of material for researchers, professionals and students in the health field, in view of the progressive increase in the elderly population over the years.

Contributions to the area of nursing and public health
The main contribution of this study to the field of gerontological research was investigating the care given by nurses to elderly people in long-term care facilities.The findings of this study showed that nursing tends to encourage health promotion actions, enhancing the self-esteem and life of elderly people in these institutions.This is a relevant finding, since the reduction or absence of self-esteem in institutionalized elderly people can affect the performance of daily activities within the facility, contributing to their isolation and significantly undermining quality of life.
In terms of advances in the area of knowledge, these involved the production and improvement of nursing care based on interventions with a positive impact on institutionalized elderly people.

CONCLUSION
Through this study, it was possible to analyze Brazilian scientific productions from the last 11 years that demonstrate the contributions of nursing to the elderly in long-term care facilities.The results showed that the contributions of these professionals to the lives of institutionalized elderly people were linked to health promotion measures, as well as simple interventions, such as listening, interacting, offering recreation and helping in pyschoaffective relationships, all of which help raise the self-esteem of these individuals.
The results also indicated that the care of institutionalized elderly people is always in constant development and, although some professionals still lack a gerontological vision, the care of this population is intrinsic to the profile of the nurse.This care is the starting point for improvement, along with training, in order to provide better care for these users who have a particular set of peculiarities.
The findings showed that, although there is an initial decrease in self-esteem among institutionalized elderly people, it is possible to note, in the short-term, that nursing helps stabilize this situation and improvements start occurring in the lives of these individuals, as they enter into a model especially organized and planned to meet their needs.
This study sought to raise positive issues for a better approach to handling the arrival of elderly people in long-term care facilities, and thereby promote better acceptance by these individuals of their new reality.

Chart 1 -
Characterization of the studies that made up the sample