Assumptions of good practices in home care for the elderly: a systematic review

Objective: To synthesize the knowledge produced on best nursing practices in long-term care for elderly at home, in order to promote healthy aging. Method: A systematic review, based on the Joanna Briggs Institute’s proposal: without restriction of dates; in the English, Portuguese and Spanish languages; conducted in PubMed, CINAHL, LILACS, Embase and Scopus databases. Results: Among 453 articles identified, 16 were included in the review: seven qualitative and nine quantitative, published between 1996 and 2015. The synthesis of the data identified as best practices identifies a premise of care centered on the elderly and the inclusion of the elderly, family and nurses as agents of this care. Conclusion: According to evidence, good practices in gerontological and nursing home care fundamentally depend on constant planning and reorganization, so that they are indeed comprehensive and contextualized. Thus, providing care will be reasoned by and driven to the elderly, based on their specific and global needs, favoring a process of healthy and active aging.


INTRODUCTION
The increase in the elderly population in developing countries has led to changes in the population pyramid. Epidemiological changes, characterized by reduction of infectious and parasitic morbidities, associated with the expansion of chronic noncommunicable diseases, are concomitant with this demographic transition. Even though there is a greater life expectancy of the population, other pathologies that can affect the autonomy and quality of life of the elderly occur (1) . Thus, it is necessary to reflect on the importance of care for the elderly throughout life, in order to provide a healthy and active senescence.
Long-term care can be provided in a variety of settings, including in the home, communities and Long-Term Care Institutions (LTC). In each of these, the caregiver has specific characteristics that are defined more by the dominant cultural model in a given society than by planning. Thus, when it comes to informal care, women are, in almost all societies, the main caretakers: an aspect that reinforces the role historically attributed to them, as well as doing housework and caring for other family members (2) .
However, regardless of the environment in which the individual elder's care is provided, and who promotes it, adequate preparation to deal with the specifics of this stage of life is necessary. It is also fundamental to encourage behaviors that favor the maintenance of autonomy and healthy aging, through the involvement of the family, health professionals and, above all, the elder in self-care, as well as the search for new creative practices (3) .
"Good practice", in Brazil, was officially stated in the Resolution of the Collegiate Board of Directors-RDC nº63 of 11/25/2011, which established the functioning of health services based on the principles of qualification, humanization of care, and the management, reduction and control of risks to the individuals and the environment (4) . This Resolution considers the care to the elder in the home to be a resource that enables humanization, controls the risks of disease transmission, and contributes to the maintenance of the elder's health in his own environment, as well as ensures care alongside his family. The proposals of this kind of care are different between countries, depending on current health policies and social conditions. Therefore, performing the initial home visit to the elder is the responsibility of health professionals. It is an opportunity to plan care and define interventions that ensure good practices for this population, always with the concern of involving the family caregiver in this process, to guarantee social safety: of health, care, and other issues (5) . The family is responsible for taking care of the elder individual (6) , although the state must establish public policies that guarantee his rights and ensure adequate health care.
Health professionals should act as agents of societal transformation, and integrate the family in the care of the elder. One of the most effective manners to promote health, through the self-care practices developed by the elder individual, is to integrate him into different activities, such as health education interaction groups. Providing formal support is another behavior that transforms daily lives, contributes to coping with the changes inherent in the aging process, and minimizes the limitations imposed by the presence of chronic, noncommunicable diseases (7) . In addition, interaction groups can be a tool for social inclusion and interaction, in the sense of salvaging the autonomy and dignity of life, from the perspective of being and remain healthy (8) .
The home setting, and the many health services by which to approach the elder, using of multidisciplinary educational interventions, as well as the development of interaction groups, have been effective strategies for strengthening autonomy and independence for healthy aging (7) . Several other actions can be implemented in the information and communication era, so that health technologies (applications, for example) can be used by both the elder individual for self-care tasks, and by health professionals who accompany them in their homes. Thus, the use of technologies for diagnostics and therapeutics has increased in the scope of care for the elderly (9)(10) .
Estimates suggest that in the next decade, long-term care will lead to significant changes in society, and so it is important that all health professionals use the benefits of such technologies carefully, and carefully reject those that harm the elderly (11) .
Population aging has become a challenge for public health, due to the high cost for health services, especially for elderly people, who have more demands for care. The greater meaning given to multiprofessional elder care, according to the new models of coping currently applied to overcome some of these challenges, the difficulty for finding qualified professionals to work in these types of care, and the lack of standardization in the care of this population, mainly at home, still constitute limitations of the Brazilian health system.
In view of the above, the objective of this study was to synthesize the knowledge of the best nursing practices in long-term care for the elderly at home, in order to promote healthy aging (12) .

OBJECTIVE
To synthesize the knowledge of the best nursing practices in long-term care for the elderly at home, in order to promote healthy aging.

METHOD
This was a systematic review, that followed the recommendations of the Joanna Briggs Institute (JBI), according to the nine steps recommended for the development of this type of study: 1) Development of the preliminary research protocol; 2) Formulating a review question; 3) Defining inclusion and exclusion criteria; 4) Search strategy; 5) Selecting studies for inclusion; 6) Assessing the quality of studies; 7) Extracting data; 8) Synthesizing data; 9) Narrative summary; 10) References and 11) Appendices (13) .
Initially, we selected studies that addressed the care provided by gerontological nursing in home care, aimed at the promotion of active and healthy aging. The studies identified reported the use of different strategies to care for the elderly population, both in Brazil as well as in other countries. We developed the guiding question based on the method proposed by the JBI, that is, we focused on the outcome of a given intervention for a population. In order to formulate the research question, we used the PICO strategy (14) ; in this case we used: "population" (P), " intervention of interest " (I) and "outcome" (O). The "comparison" (C) was not applicable to this search. Finally, we defined the following research question: "Do good practices of gerontological nursing in home care and long-term care contribute to active and healthy aging?" The following inclusion criteria were established: 1. Primary studies; 2. Periodicals published in Portuguese, English and / or Assumptions of good practices in home care for the elderly: a systematic review Rodrigues  we read the articles in their entirety, in order to select those that met the pre-established inclusion criteria for the final analysis (15) . Throughout the process of searching for and selecting articles, we adopted the PRISMA protocol ( Figure 1), with the intention of carefully planning and organizing the study and, thus, ensuring the development of a rigorous systematic review (16) .
As a reference for the analysis and extraction of data from the selected studies, we chose the instrument developed by Ursi (2006) (17) . The results were organized by means of a descriptive synthesis of quantitative and qualitative data.
In this study, we analyzed public and free access articles, available in the databases of the scientific literature and, therefore, there was no need for submitting the study to the Research Ethics Committee in the CEP/ CONEP System, according to CNS Resolution 510/2016 (18) . We declare no conflict of interest in the execution of this review.

RESULTS
In the critical evaluation of the included articles (Chart 1), we considered the quality of studies adequate. Two of them did not specify the methodological framework used, and another one did not perform a sufficiently rigorous analysis of the data. On the other hand, the studies presented an adequate relationship between the proposed objectives and the research design, and described the results clearly, which contributed greatly to the understanding of the object of study.
The descriptions of the authors of the 16 articles were analyzed before the research question were reviewed, and separated according the type of research, that is, quantitative (9) or qualitative (7). The results were grouped into two stages, based on the analysis proposed in the study. 1 "Studies identified in other sources" refers to research published in scientific journals not indexed in the databases selected for this review. "Inappropriate research type" encompasses non-primary studies that were only identified after reading the article in its entirety.
The searches were conducted in April of 2018, in the following databases: National Center for Biotechnology Information (NCBI/PubMed), Cumulative Index for Nursing and Allied Health Literature (CINAHL), Excerpt Medical Database (EMBASE), Latin American and Caribbean Literature in Health Sciences (LILACS), and Scopus. We used the combination of controlled and uncontrolled descriptors, as indicated by each database. The articles in PubMed were accessed using Medical Subject Headings (MeSH) controlled descriptors; Heading-MH was used for the CINHAL database; for the search in EMBASE, we adopted the Embase Subject Headings (EMTREE); and the Health Sciences Descriptors (DeCS) were used to search within LILACS. For this search, we used "Long-term care", "gerontological nursing", "home care" and "healthy aging". We used the Boolean operator "AND" in all combinations as follows: "healthy aging AND gerontological nursing AND home care AND long-term care". We searched for articles in English, Spanish and Portuguese languages, and did not stipulate a time limitation for the publications. For selection of articles, we used the Rayyan application, developed by the Qatar Computing Research Institute (QCRI), which supports systematic reviews and facilitates the selection process of the studies. The reading of articles occurred in three stages: in the first, searches were conducted in the databases; in the second, three authors read the title and the abstract of the articles, in order to separate them for the next phase; and finally, in the third stage,  Note: Critical Appraisal Skills Programme (19) (CASP).

Synthesis of Results of Quantitative Studies
The quantitative studies included in the systematic review were published between 2004 and 2015 (Chart 2). All characterized the population investigated by collecting socio-demographic data (age, gender, and marital status) and highlighted two main themes: health education, and, program and care protocol.
In health education (20)(21)(22) , the variables investigated were related to aspects of daily life of the elderly individuals, such as medication administration and adherence, depression, social support, and knowledge about chronic diseases.
In the program and care protocol (21)(22) , the following themes were emphasized: cognition, self-administration of medication, dyspnea, pain, cutaneous integrity, functional dependence, health complaints, quality of life, knowledge, and adherence to treatment for arterial hypertension.
The objectives of the quantitative studies were the impact analysis of the nurse home visit, with regard to self-care promotion for elderly individuals with chronic, non-communicable diseases.
The methodological delineations described in the research differ, but we identified a predominance of quasi-experimental (20)(21)(22)  and transversal studies (23)(24)(25) , as well as experimental (26)(27) and longitudinal studies (28) . With regards to the results, the authors stated that educational interventions could be considered a good practice to be promoted by nurses, who provide care for elders in home care, as well as an instrument that favors the adoption of other good care practices for their daily lives. The effectiveness of these interventions was evidenced both in the improvement of self-care of the elderly, and in the nursing care provided, so that their impact can be attributed to specific nursing interventions.
Such studies have described satisfactory outcomes for pain management, adherence to health promotion groups, awareness of attitudinal change, medication self-management, pressure injury prevention, knowledge of chronic diseases (hypertension, for example), medication adherence, self-confidence in treatment, cognition, dyspnea, pain, depression, social support, and improvement in basic activities of daily living and instrumental activities.

Synthesis of Results of Qualitative Studies
With regards to the qualitative articles, seven studies were included, published in Brazilian and Portugal periodicals between 2009 and 2013, five of them performed in Brazil (29)(30)(31)(32)(33) and two in Portugal (34)(35) . The general characteristics of these studies can be seen below (Chart 3).
In relation to our objective to identify some assumptions for good practices, the qualitative studies analyzed presented relevant topics: health education, support network, environment, specific needs of the elderly during the process of senescence and senility, self care, family, relationship, and health professionals. These are themes that, although they do not represent the good practices themselves, are characterized as guidelines for their composition.
The studies presented in Table 3 indicate the predominant use of the interview as a tool for data collection (29)(30)(31)(32) , but add other forms, such as documentary analysis (31) , participant observation (29) , data recording (33) and photovoice (35) . This latter is a method of data collection conducted in a more participative manner, as the subjects of the research are manifested by identification of images that best represent their positions in relation to the subject investigated, and present their own interpretations about the meanings of this relationship.
With regard to analysis, the use of exhaustive reading, coding, and identification of the related categories was predominant (29,(31)(32)35) , an analysis process that is equivalent to thematic content analysis. However, one of the studies opted for content analysis by three independent experts (35) , so that the findings could be validated with greater rigor. One of the publications used the discourse of the collective subject (30) , and another incorporated a qualitative data analysis software (34) , confirming the strong tendency to use technological resources in this type of study.
The articles analyzed presented categories that can support the planning of home care for the elderly based on good practices. The results were grouped into four categories: object, instrument, purposes, and agents. These topics are identified as components of the health work process that can guide the development of good practices in gerontological nursing during specific actions, such as home care. Therefore, we can observe a direct relationship between the identified need, the work to be performed, and the organization of health service. The need identified in the review is the elderly patient who is at home. The work to be performed is nursing care, and the organization of the service signifies home care. Thus, the synthesis of findings presented in this review enables us to identify aspects that are related in practice, in a dynamic and continuous interaction, in development of good practices in gerontological home care nursing.

DISCUSSION
This analysis enabled the identification of good actions developed by nurses in the context of home care for elderly individuals, as well as the participation of the family in this process. Quantitative and qualitative studies refer us to successful experiences, which need to be encouraged and included in nurses' gerontological practice.
The quantitative studies report different actions in the care provided to the elderly. Good health practices have been described as an important tool for promotion of active aging, for strengthening the autonomy and independence of the elderly, as well as for exercising a biopsychosocial impact. Rodrigues (29) et al, 1996 The developed actions had a diverse duration, but were beneficial to the participants, as well as efficient in improving self-care and the care provided, and increased the participation of the elderly in health promotion groups. Self-care is a manner of maintaining the independence of the elderly individual, even when he is debilitated by some chronic condition (20,22,25) . Thus, health promotion groups also stand out for making people's knowledge known, and for expanding the social support network, promoting changes in the quality of life of the elderly by means of interpersonal interaction (36)(37) .
One study (24) identified the following factors that most influenced the need for home visits by the nursing professional: being male, dependent for activities of daily living, having pressure injuries, and receiving emergency medical care at home. In contrast, according to the study, patients with severe cognitive impairment are less likely to receive home visits, and those with a pressure injury are four times more likely to require home visits. This study supports us in the management of cases and in the development of programs for this type of visit, as it identifies possible demands and outlines a profile of the target population.
Acting in environments where the elderly feel safer and more comfortable can have an even better impact; home interventions influence daily life to the point of changing eating habits, interfering with medication use, and encouraging the practice of physical activities. It can also arouse critical thought regarding fall prevention (38) .
Health education is one of the actions most accomplished by nurses. It is an important tool for self-improvement, with automatic and positive influences in the community. The educational development of community nurses enables effective meetings, which promote the self-efficacy and clinical outcomes of the elderly with chronic conditions. Health education also provides other benefits for the elderly, such as the reduction of depressive/anxious symptoms, and an improvement in cognitive performance (28,39) .
The important role of nursing in health promotion and active aging was evidenced in the authors' conclusions, which described satisfactory and positive outcomes. The described actions were performed in several environments, ranging from homes to hospitals (27) .
In general, qualitative studies corroborate the quantitative findings, especially regarding the importance of educational actions in home care for the elderly (29,(32)(33) , the perception about the contributions of the home environment (29)(30)(31)(34)(35) , and the relevance of the role of nursing in this context, based on the careful planning of care for the elderly (29,(31)(32)(33)(34)(35) .
The themes identified in the analyzed studies were grouped and arranged in the health work process model. The authors of this study identified and named the components of the health work process as follows: object, purpose, instruments, and, agents (40) .
Thus, the themes identified in the 16 articles were related to the object of the work process and, in this item, we note that the elderly person has excelled as the object of constituted care. Providing care begins with identification of the elderly individual, as a center to be perceived in his family and community context, with his specific characteristics, peculiarities, needs and possibilities. In home care, the planned care should begin with and be completed for the elderly individual. Thus, by centralizing the care provided to the elderly, we initiate an essential technological innovation in care, focusing on light technology using humanization, welcoming, and empowerment (41)(42) .
In the context of home care, the elderly individual occupies a fundamental role: in addition to being the object of care, he acts as an agent, because his active participation in providing his own care is indispensable and determinant. Thus, the component related to the agents is now composed primarily by the elderly. Next, we highlight the family, as the agent that directly mediates the environment and the conditions in which the elder will be integrated, favoring or hindering his decision-making. The family members are characterized as informal caregivers, and their actions directly influence the quality of care provided to the elder. Finally, in the composition of the agents, we identified the health professionals as elements external to the family environment, and responsible for the establishment of evidence-based care. They should also propose specific goals for recovery, health promotion, and disease prevention (30,(34)(35) .
We also identified some important aspects with regards to the instruments needed for care in this context. Instruments are the resources used by agents with the purpose of transforming the object of care. Thus, in the articles included (29)(30)(31)(32)(33)(34)(35) , three instruments were found as basic for the care of the elderly in a home environment. The first one was the educational process, which is divided into three directions: the first directly influences the elder, as it includes the process of strengthening his autonomy. The other direction is represented by the family, recognized as an agent in the process of care provision, as it directly interferes in decision-making in the family environment. Finally, there is education with the professionals involved, whose objective is to enable them for specific care (43)(44)(45)(46) .
The purpose component represents the intentionality of the whole process as it is initiated, and which is determined by the choices made. In the elderly, the purpose is the priority, as the aging process is identified as a constantly changing variable. Care without adequate planning can, therefore, only briefly solves a problem, but the failure to identify the primary cause poses risks in the medium-and long-term.
Therefore, studies indicate that it is necessary to meet the specific needs of the elderly, without compromising their healthy aging. The research also showed that the ultimate goal of care for the elderly in the home environment should be the maintenance of their functional capacities, with the preservation of their autonomy. This should be the nurse's intentionality in the planning of care for all situations, regardless of whether it is the first visit, a segment evaluation, or an emergency intervention (31)(32)35) .
We also detected the importance of the nursing team relationship with the elderly person in the home environment, basically characterized by a continuous interaction, capable of developing feelings of trust or distrust. Thus, the power of this interaction will be directly proportional to the quality of the information flow, that will support the planning and execution of care. In addition to the interaction, the studies highlighted the need for careful planning for care education, which can involve all participants in the process, including the elderly individuals themselves, to enable them to make decision for their day to day lives (29)(30)(31)(32)35) .
This analysis showed that all the variables and themes identified were dynamically and consistently related to information feedback, knowledge, and attitudes, with rotation of the protagonist, but always having the elderly individual as an objective and guideline for providing care in the home environment.
Next, Figure 2 presents a representation of the synthesis, both narrative and thematic. Despite the heterogeneity of the articles, common thematic categories were identified, which enabled us to align the results and present a meta-aggregative scheme of those most cited (13) .

Study limitations
The results of this review are based on the analysis of the 16 articles and show us that gerontological nursing needs to move forward with proposals of good actions to care for the elderly in their home environments. In general, the qualitative publications on the subject still need more methodological rigor in terms of the definition of the theoretical reference and analysis.

Contributions to gerontological nursing and elderly health
The increase in the elderly population predicted for this century denotes a period of reorganization of the society, including the health system and nursing care. Nurses, as care managers, should be prepared for this new demand. The development of research with the objective of promoting good home care practices will be fundamental to increasing knowledge, but the instruments of work should be based on different technologies of care, so that people can grow old and live in their homes with comfort and security.
In addition, as the health systems have prioritized health care at a lower cost and in the person's own environment, we consider that the development of good practices in home care for the elderly meets the need for a market that has limited financial resources.
Nursing practice is based on the interaction and articulation with other health professionals, in a model of multiprofessional performance that demands flexible professional protagonism. In this context, proposals to implement care protocols based on the use of different methods and techniques are essential for advances in this area.

FINAL CONSIDERATIONS
This review demonstrated the need for including the elderly individual and his family in the planning of gerontological home care nursing, because this favors the provision of care effectively focused on the needs of the elderly person, and enables him to adapt to the family environment and the possibilities of collaboration of those with whom he shares the same space. The results of the analyzed studies show that this type of care also contributes to the strengthening of ties between the elderly individual and his relatives.
With regards to the adherence and continuity of the proposed intervention, health education plays a fundamental role, because it allows all involved to understand and choose to participate in the process of caring. In this way, establishing health education planning enables the empowerment of the elderly, strengthening their autonomy and independence, and training their families and informal caregivers, so that they feel secure in the decisions and actions they must take.
Good practices in gerontological home care nursing, according to the evidence, essentially depend on careful planning and organization, so that they are dynamic, inclusive, and contextualized. Thus, the production of care will be based on and guided by the elderly, based on their specific and global needs, which will favor a healthy and active aging process.
We conclude that researchers in this area of knowledge need to use research methods that offer more applicable results, and should use the theory of self-care related to autonomy and independence of the elderly, which favors active and healthy aging.