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Acta paul. enferm. vol.25 no.2 São Paulo 2012
Elderly residents in long-term institutions: the use of spaces in the construction of everyday life*
Ancianas residentes en instituciones de larga estancia: uso de los espacios en la construcción del cotidiano
Maria Eliana Peixoto BessaI; Maria Josefina da SilvaII; Cintia Lira BorgesIII; Geridice Lorna Andrade de MoraesIV; Cibelly Aliny Siqueira Lima FreitasV
IM.Sc. in Nursing. Ph.D. student,
Graduate Nursing Program, Universidade Federal do Ceará- UFC - Fortaleza
(CE), Brazil; Propag-Reuni Grantee. Fortaleza (CE). Brazil
IIPh.D. in Nursing. Associate Professor at Universidade Federal do Ceará - UFC - Fortaleza (CE), Brazil
IIIUndergraduate Nursing Student, Universidade Federal do Ceará -UFC - Fortaleza (CE), Brazil
IVPh.D. student, Graduate Nursing Program, Universidade Federal do Ceará - UFC - Fortaleza (CE), Brazil
VPh.D. student, Graduate Nursing Program, Universidade Federal do Ceará - UFC - Fortaleza (CE), Brazil; Faculty, Nursing Program, Universidade Vale do Acaraú - UFA - Sobral (CE), Brazil
OBJECTIVE: To understand the way in which
the institutionalized elderly organize their living spaces for their daily life.
METHODS: A qualitative study that used the strategy of a case study, conducted in a long-term institution for the elderly (LTCF), located in the city of Fortaleza - CE (Brazil). Participating as subjects were nine elderly residents of this institution, during the period between April and May, 2006. To collect data, we used direct nonparticipant observation, with the field notes on the interview kept in a journal based on the script of life history.
RESULTS: The reconstruction of individualized spaces was marked by the institution's organizational structure, use of common spaces and such as the elderly rearranges his own universe.
CONCLUSIONS: The (re)construction of the daily life of elderly in the LTCF context is a complex process that requires effort of the elderly. In this study, we observed that the elderly are able to restructure their lives.
Keywords: Aged; Homes for the aged; Housing for the elderly; Adaptation; Case studies
OBJETIVO: conocer el modo cómo
la persona anciana institucionalizada organiza sus espacios para vivir el cotidiano.
MÉTODOS: Estudio de abordaje cualitativo que utilizó la estrategia del estudio de caso, realizado en una institución de larga estancia para ancianos (ILPI), localizada en la ciudad de Fortaleza-CE. Participaron como sujetos nueve ancianas residentes en esa institución en el período de abril y mayo del 2006. Para la recolección de los datos, se utilizó la observación directa no participante, con el registro en el diario de campo de la entrevista basada en la guía de historia de vida.
RESULTADOS: La reconstrucción de los espacios individualizados fue marcada por la estructura organizacional de la institución, utilización de los espacios comunes y cómo la anciana reorganiza su universo particular.
CONCLUSIONES: La (re) construcción del cotidiano del anciano en el contexto asilar es un proceso complejo que necesita de esfuerzo del mismo. En este estudio, se observó que las ancianas están consiguiendo reestructurar sus vidas.
Descriptores: Anciano;Hogares para ancianos; Viviendas para ancianos; Adaptación; Estudios de casos
Daily reality is the life of every day and every man. In this context, personality aspects develop and, to experience them, senses, intellectual skills, manipulative abilities, feelings, passions and ideologies are used (1).
The increased population group of elderly people and the lack of formal or informal caregivers result in a growing demand for institutionalization in that age range (2).
Long-term care facilities (LTCF) take charge of care delivery when elders lose their bonds with their social network, giving support or seeing to their needs with a view to improving their health and quality of life (3).
LTCF are establishments that serve to deliver institutional comprehensive care to people aged 60 years or more, whether dependent or independent, who are in no conditions to stay with their family or in their homes, providing them with housing, meals, health and social contact (4,5). This care mode serves as a substitute family.
In these places, daily life is marked by a routine filled with rules and preset times, without further flexibility to establish an autonomous routine (6), which distinguishes these institutions from the family environment.
This strictness approaches LTCF to what are called total institutions, places of work and residence where a great number of people are socially isolated and, in their reclusion, share a formally administered daily routine (7). These environments hamper interpersonal communication in the community context and limit social and affective life.
In institutional life, elderly people need to establish new relations and delimit spaces, guided by their former lifestyle. Therefore, research on the adaptive processes of elders in LTCF are relevant in view of the growing need for these institutions.
In an on-line search in LILACS, using the words "daily reality" and "long-term care facilities", only seven scientific contributions were found, among which Ximenes(8) is highlighted, who studied the institution, its daily reality and the elderly's free time, departing from the reality of daily institutional life.
Institutionalized elders need more care than therapeutics. Therefore, nurses, as caregiving professionals, need to be inserted in the reality of daily life at the LTCF, performing administrative, care, educative, teaching and research functions (9). Thus, they are expected to contribute to improve institutionalized elderly people's quality of life (9).
This study aimed to get to know how institutionalized elderly people organize their spaces for living daily reality.
In this qualitative research, the case study strategy was used, adopting a comprehensive perspective.
Case studies [...represent the preferred strategy when questions like "how" and "why" are asked, when researchers have little control over the events and when the focus rests on contemporary phenomena inserted in some real-life context...](10).
Understanding means mutual understanding, one understanding the other. Its essential trait is the inter-relation between the whole (context) and the peculiar (individual); what gives meaning to the peculiar, at the same time as the contextual sense can only be found in the individual. This coming and going between the peculiar and the whole is therefore the base of understanding (11).
The study was developed at an LTCF in Fortaleza-CE, located in a neighborhood near the city center and which houses women only. A religious order maintains this philanthropic institution. This establishment consists of two distinct and spatially separated areas, called Boarding House and Village. The institution was intentionally chosen for the present study, after having visited LTCFs in Fortaleza.
The Boarding House comprises 18 individual houses, all of which are fully equipped (room, kitchen and bathroom). Residents in this area are freer to organize their daily activities.
The Village infrastructure can receive 42 elders, and installations were projected for them to live alone. There exist two room types though: fully equipped rooms (like in the Boarding House) and lodgings, which consist of a room only. In the latter, bathrooms are located in a common area and are collective. The people living in that area are subject to institutional standards and routines. At the time of study, the Village at the LTCF was full.
The following inclusion criteria were adopted for sampling purposes: living in the Village, willing to participate in the study, indicating other elderly residents and serving as a reference in the relational dynamics at the LTCF. The elderly women were identified as references after non-participant observation and through conversations with the nuns responsible for the LTCF. Nine elderly women participated in the study.
Upon her arrival at the institution, the residents were curious to find out who the researcher was and what she was doing there; thus, that person's presence changed the elderly's daily reality. It was only after one month of daily visits to the LTCF, when the elders no longer perceived the researcher as an external element, that data recording and collection started.
Six observation visits took place between April and May 2006, which took an entire morning or afternoon, and were aimed at observing the daily reality of the institutionalized elderly.
Next, between May and July 2006, interviews started, based on the oral life history script, whose contents ranged from the motivations that made the elderly woman turn to the institution to her daily reality experienced at the time of the research.
The first participants were chosen according to the Case Study method: women who had spent more time at the LTCG, who helped more, who were more reserved, who were always near the entry of the LTCF. Others were chosen upon the former's indication with a view to trying to establish the dynamics of mutual relations.
In this paper, the field diary notes will be discussed, without including the data obtained from the interviews. Records were made at the end of each study day. The outlined spaces and the women's daily movements were written down, as well as the institution's standard functioning, besides discourse fragments among the elderly and informal conversations, after each observation round.
For the sake of an easier understanding, a sketch of the LTCF was elaborated, on which these movements were drawn so as to outline the territory the elderly women covered during the observation period.
To validate impressions from the observation period, questions were asked during the interviews about the spaces occupied in daily reality, confronting the daily life of the interviewee, her peers and the services the institution offered. Observations were interrupted when no more novelties were identified in the institution's daily reality.
Data analysis considered the individual constructions of daily life, the relations established among the elderly, confronted with the institutional standards.
This study is part of a Master's thesis and received approval from the Research Ethics Committee at Universidade Federal do Ceará, under Protocol number 55/06.
The institution agreed with the researcher's presence. Before the interviews, the Informed Consent Term was signed. To safeguard the research subjects, each of them received a flower name as a pseudonym.
To understand how the elders reconstruct their private spaces at the LTCF, first, it is important to understand how common spaces are structured before entering these elderly women's private universe.
The elderly women are received at the LTCF soon after they are institutionalized, which can facilitate their adaptation. The strategy the LTCF uses to enhance integration among the elderly is to put those women who have spent more time at the institution and are more adapted to institutional life in charge of welcoming newcomers. The institution is concerned with selecting younger and more autonomous women for this task. On the occasion of the research, Gardenia played this role, who had been living at the LTCF for three years and eight months and was welcomed by the nuns because she had no place to live.
Gardenia establishes the link between the newcomer, the external environment and family and the internal environment at the LTCF. Other elders had performed this role, including: Violet (80 years and living at the LTCF for ten), Margarida (79 years and living at the LTCF for 31) and Hydrangea (73 years and living at the LTCF for six years). These women were replaced due to their advanced age or because they did not want this responsibility anymore.
The LTCF routine starts at six a.m., when mass is celebrated at the chapel. Breakfast is served at the lunchroom at 7 a.m. At 9 a.m., there is a snack and lunch is served at 11 a.m., finishing the morning period. In the afternoon, routine starts at 1 p.m., when a snack is served. At 2 p.m., the women pray the rosary with one of the nuns and, at 3 p.m., another snack is offered. Finally, diner is served at 5 p.m.
Visiting times go from 8 to 10.30 a.m. and from 2 to 4 p.m. During that period, some relatives visit, as well as students from a private college in Fortaleza who were doing their practicum on certain days. The elders hardly participated in these activities due to a lack of interest or because they found them repetitive.
The common areas are: the lunchroom; a cave with the image of a Catholic saint; a long corridor leading to all institutional areas; the chapel and the laundry, the latter of which only Vila residents use.
Every day, Violet, Jasmine, Margarida, Lotus and Rose attend the chapel. Orchid and Gardenia only attended on Saturdays and Sundays and Hydrangea only on Saturdays. The nuns responsible for administering the LTCF stimulated religious rites.
The lunchroom is a large area where each inhabitant has her designated space. Many of them do not eat there though, such as Violet (80) and Margarida (79). Although spaces at the lunchroom are designated, in case of conflicts between elders at the same table, the persons in charge change the places. The women are not allowed to change places autonomously. That happened with Orchid and Gardenia, after misunderstandings due to daily problems, such as: gossip, "badmouthing the other", besides criticism and observations regarding relations outside the LTCF environment.
Also concerning the lunchroom, Hydrangea takes her meals with Leave, a newcomer at the LTCF. According to Leave, Hydrangea has been the support needed to stay at the institution.
A bell is rang to announce meals. For snacks, the women leave their houses or are already waiting in the corridor, each of them with their own cup. They receive cookies and porridge, the most frequently offered foods, eat and then put their cup in the kitchen to be washed.
At lunchtime, the servants distribute ready-made plates among the elders' places and, at the end of the meal, they take their plates to the kitchen for the servants to wash.
After the afternoon snack, some women tend to meet with a nun to recite the rosary, a Catholic devotion dedicated to Mary. On these occasions, it was observed that Jasmine and Orchid generally spend time together. After the rosary, the nun reads an excerpt from the Bible and meditates.
The shared prayer is often interrupted by Petal, an elder clinically diagnosed with Alzheimer's, who lives at the institution's infirmary and is frequently found in the corridor.
The corridor that provides access to all institutional areas is a space the elders use in different ways. They explain what they do as follows: look at the trees and birds (Hydrangea), watch television (Violet), welcome people who come to visit and exercise, such as walking (Margarida) or even wait for time to go by (Azalea). That is a routine most elders who can move around independently adopt.
Another less mentioned but very important common area is the clinic, located outside the institution, which Azalea attends three times per week because of her physiotherapy, and other elders because of diabetes mellitus and arterial hypertension monitoring.
Although it is a common space, the elders hardly use the laundry. The women who wash their clothes do it at their homes, while institutional servants are left in charge of heavier laundry, such as hammocks and sheets. These servants assist in common as well as private areas, distributing meals at preset times, cleaning the women's rooms and washing their clothes.
Private space - reconstruction of the elderly women's individuality
The elders called the small space the institution reserves for each their home or apartment. This is one of the aspects that distinguish this LTCF from others in Fortaleza. All of them live alone, i.e. they do not divide their space with other women, except for some who share the bathroom. The only area where two or more elders stay together is the infirmary and, at the time of study, only Petal was staying there. The fact that the institution locates only one room for each elder enhances the reconstruction of individuality.
Although the institution has a strict time routine, there is room for isolated activities, to each elder's liking. At those times, they attempt to preserve their intimacy, although this is difficult due to institutional confinement. Freedom is to accomplish activities necessary for each woman's daily life, such as cleaning their own houses, even if the institution offered that service; bodily care, such as waxing their legs at the door of their house without any constraint. Others, despite knowing that they have health problems, smoke cigarettes or pipes.
In the intimate sphere of their home, all of them perform activities of daily living, such as cooking, washing, ironing clothes and doing the dishes. Although there are people available to do this, many of them prefer to perform these activities, as they want to arrange their belongings as they wish. That is one way of bringing fragment of their life before entering the LTCF into the institutional space.
Some have television or radio at home, so that, when the institution closes its doors and the elders go to their rooms, they continue living their daily life to their liking.
Although the institution offers different prayer sites, some elders still prefer doing these activities alone, inside their room.
The reconstruction of the women's individuality is intermixed with interpersonal relations. At the institution, both the interview contents and field diary records revealed that relations among the residents are very subtle. The large majority establishes superficial relations and remains limited to formal greetings like: "Good morning!", "Good afternoon!", "How are you?". They mention acting that way to avoid gossip and intrigues.
It is an environment in which people from different social and economic contexts exist, which in turn causes rejection by the other inhabitants.
Another aspect that was identified was the need to respect the other women's limits. This is strongly present in community life at the institution. The sole moments of encounter (contact) happen at the lunchroom, when praying the rosary and, sometimes, when they are sitting in the corridor waiting for meals.
Some women maintain a stronger bond with another resident, such as: Violet with Orchid, Hydrangea with Leave, Gardenia and two other friends. Others, like Gardenia and Orchid, also maintain relations with people outside the LTCF. Only Orchid and Hydrangea maintain family bonds though. All elders have a good relation with the servants and nuns, people who, according to them, give them kindness and attention and are compared with substitute families.
The entry into the LTCF is a difficult phase, as the elderly women has to abandon a life history, with her habits, social support network and daily reality to (re)construct another, sometimes fully rejecting current circumstances.
To provide high-quality care to its residents, an LTCF should attempt to be similar to a house, concerning architecture as well as programming, with details that remind of a house, a home and family life(12); respecting individuality and enhancing social spaces that remind of homes: with clear and varying colors, furniture and utensils that offer comfort, hygiene and safety(13). In that space, the LTCF under analysis approaches literature descriptions on architectonic forms and the preservation of spatial individuality. Despite the existence of common areas, these are hardly used due to the residents' voluntary isolation.
An established resident's participation to receive a newcomer at the institution helps with the new inhabitant's adaptation and with changed perceptions on the LTCF, as relatives, elders and society in general have many questions, fears, expectations and prejudices related to the hospitalization(14).
Generally, the first meeting between the elderly/family/LTCF triad happens in a climate of indecisions, guilt and insecurity. Transparent involvement and a relation of horizontality would permit the minimization of negative feelings, especially for the family and the elder (15); therefore, the latter's institutionalization needs to be well planned and jointly decided on.
Welcoming also contributes for institutional standards and routines to be presented (12,14,16) to the newcomer. The fact that some of the elders in the study chose to live at the LTCF facilitates this process.
One may supposes that established rules at the institution under study hamper the reorganization of the elderly women's daily lives. Knowledge on their life history and habits concerning activities of daily living and what they like to do day by day (17) can contribute to the adaptation process.
The fact that the LTCF provides isolated housing facilitates the accomplishment of some daily activities alone, although to a limited extent, maintaining independence and autonomy, so as to preserve dignity, personal value, freedom and individuality (18).
In any context, the elders need to be treated as unique beings, using language, which is fundamental for their development as subjects, as it allows each individual to interact, i.e. to communicate with the environment. Hence, each individual is a product of the set of surrounding social relations (19). At the LTCF, this communication is impaired by each inhabitant's care not to reveal her weaknesses, as each gesture discloses not only who she is or her origins, but also her singularities, thus outlining spaces and interaction possibilities (19). This concern not to disclose oneself is constant in interpersonal relations at the LTCF.
The feeling of belonging to a group is what supports the social relations; thus, the existence of communities becomes necessary, as they come from a space where individuals can establish closer, intimate, i.e. more personal relations (14). Interpersonal relations are therefore extremely important to deal with new and stressing situations.
It is perceived in the elders' daily life, however, that their interpersonal relations are subtle. Some can spend hours next to another inhabitant without even looking at her. These impressions also underline what literature mentions about interpersonal relations at LTCF (7,14, 20-21), [...the fights, the gossip, that is, the presence of other old people make life at the LTCF disappointing...](7). Observations permitted the inference that the elderly prefer to keep distance, merely using simple expressions like: "Good morning!", "Hello!", "How are you?", "Good afternoon!".
Another aspect evidenced in this study was the elders' religiousness. For many people, religion is the most important personal reference framework. This can be particularly true for adults in the second half of their lives (22). At the LTCF, religiousness also works as a form of encounter between elderly women with satisfactory relations, besides being a way to spend time.
Daily reality at the LTCF is that of [...a place where time stopped...](14), the day boils down to [...eating, sleeping and watching television...](20) breaking with their previous daily life, which was linked with work and family relations and friends, [... the order is to rest, dialogue gets scarce, mainly with external people, cutting links with the community and the family](23).
Also concerning religious practices, literature appoints some benefits, such as maintained self-esteem and quality of life in old age. The search for meaning in the trajectory of life, based on some belief, seems to fully strengthen individuals, ranging from the most active to the weakest persons (24).
The obtained results are specific for one LTCF mode, i.e. housing only women. The method can be replicated for studies in different contexts though, thus permitting generalizations.
The obtained results remit to a reality that is not very different from other spaces with similar characteristics in empirical terms. Literature on the use of spaces in LTCF is still scarce, but we consider that these institutions are extremely important, due to the residents' reality and repercussions on their quality of life.
Knowing the daily organization of institutionalized elders reveals their spatial restriction for different reasons, but fundamentally because of the need for distinction.
The observation time used was sufficiently to apprehend the full range of daily dynamics at the LTCF and among the elders. The researcher was not allowed to stay during the night, which represented a study limitation.
As the main finding, we highlight the elders' use of spaces. They are all delimited, identified, unaltered, except for some contingencies like death, fights and changes in health conditions and roles played. Concerning quality of life, this can be compromised by voluntary confinement inside the LTCF's confinement.
The method used, i.e. non-participant observation and data collection after a long stay at the LTCF, showed to be effective, as little or hardly anything changed the elders' daily life during data collection. What should be highlighted is that informal dialogues were established after the researcher left the space used for observation, moments that provided valuable information for the study.
As a care profession, Nursing should consider these findings with a view to care planning and the formulation of research and intervention projects, such as leisure and interpersonal interaction activities in LTCF areas.
Institutionalization can be a traumatizing and depersonalizing experience. As observed, however, the elderly women in this study are able to restructure their lives.
As a recommendation deriving from the study results, integration and collective experiences should be sought for institutionalized elderly, in view of different postures towards life and the present context, so as to enrich these relations, instead of the isolation detected in this research.
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Maria Eliana Peixoto Bessa
Rua Graciliano Ramos, nº 331 Bairro de Fátima,
CEP: 60415-050 Fortaleza (CE) Brasil.
Received article 27/05/2010 and accepted 27/08/2011
* Part of the master's thesis presented to the Graduate Nursing Program at Universidade Federal do Ceará - UFC - Fortaleza (CE), Brazil.