Forensic nursing care for older adults in situations of violence: a scoping review

Santos, Jiovana de Souza; Santos, Rafael da Costa; Araújo-Monteiro, Gleicy Karine Nascimento de; Santos, Renata Clemente dos; Costa, Gabriela Maria Cavalcanti; Guerrero-Castañeda, Raúl Fernando; Souto, Rafaella Queiroga

Abstract

Objective

To describe forensic nursing care for older adults in situations of violence.

Methods

This is a scoping review based on the Joanna Briggs Institute recommendations. The searches took place in 15 databases, including studies published between 1990 and 2019 in English, French, Spanish, and Brazilian Portuguese. For study selection, the flow diagram Preferred Reporting Items for Systematic reviews and Meta-Analyzes extension for Scoping Reviews was used; 17,378 studies were found, of which 19 articles were eligible for review.

Results

Nursing care for older adults in situations of violence is dynamic and varies across continents. Nurses investigate the case through clinical assessment, denounce the authorities, register, notify and activate the multidisciplinary team.

Conclusion

Using diversified strategies, nurses work with the objective of solving the problem of elder abuse, even if they encounter difficulties.

Aged; Elder abuse; Forensic nursing; Nursing care; Violence

Resumo

Objetivo

Descrever o cuidado da enfermagem forense ao idoso em situação de violência.

Métodos

Trata-se de uma scoping review com base nas recomendações do Joanna Briggs Institute. As buscas ocorreram em 15 bases de dados, tendo como inclusão estudos publicados entre os anos de 1990 a 2019, nas línguas: inglesa, francesa, espanhola e portuguesa. Para seleção dos estudos foi utilizado o diagrama de fluxo Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Foram encontrados 17.378 estudos, destes, 19 artigos foram elegíveis para a revisão.

Resultados

O cuidado da enfermagem ao idoso em situações de violência é dinâmico e varia entre os continentes. Os enfermeiros investigam o caso por meio de avaliação clínica, denunciam as autoridades, registram, notificam e acionam a equipe multidisciplinar.

Conclusão

Lançando mão de estratégias diversificadas, os enfermeiros atuam com objetivo de solucionar o problema da violência contra o idoso, ainda que, encontrem dificuldades.

Cuidados de enfermagem; Enfermagem forense; Idoso; Maus-tratos ao idoso; Violência

Resumen

Objetivo

Describir los cuidados de enfermería forense a adultos mayores en situación de violencia.

Métodos

Se trata de un scoping review basado en las recomendaciones del Joanna Briggs Institute. Las búsquedas se llevaron a cabo en 15 bases de datos e incluyeron estudios publicados entre los años 1990 y 2019, en idioma inglés, francés, español y portugués. Para la selección de los estudios se utilizó el diagrama de flujo Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Se encontraron 17.378 estudios, de los cuales 19 fueron elegibles para la revisión.

Resultados

Los cuidados de enfermería a los adultos mayores en situación de violencia son dinámicos y varían entre continentes. Los enfermeros investigan el caso mediante evaluación clínica, denuncian ante las autoridades, registran, notifican y llaman al equipo multidisciplinario.

Conclusión

Utilizando estrategias diversificadas, los enfermeros actúan con el objetivo de solucionar el problema de la violencia contra los adultos mayores, aunque enfrenten dificultades.

Anciano; Atención de enfermeira; Enfermería forense; Maltrato al anciano; Violencia

Introduction

Forensic nursing (FN) is a recently consolidated area in Brazil. It is the application of nursing science to forensic aspects of health care.(¹1. Felipe HR, Cunha M, Ribeiro VS, Zamarioli CM, Santos CB, Duarte JC, et al. Questionário de Conhecimentos sobre Práticas de Enfermagem Forenses: adaptação para o Brasil e a propriedades psicométricas. Rev Enferm Ref. 2019;4(23):99–110.)In other countries, FN is much more developed when compared to the Brazilian context, such as the USA, where the International Association of Forensic Nursing (IAFN) was founded, in 1992, by nurses who acted as examiners of sexual abuse and, in 1995, the American Nurses Association (ANA) recognized FN as a specialty.(²2. International Association of Forensic Nurses (IAFN). History of the Association. Elkridge: IAFN; 2018 [cited 2021 Feb 21]. Available from: https://www.forensicnurses.org/page/AboutUS
https://www.forensicnurses.org/page/Abou... ) In Brazil, this recognition only occurred in 2011, but only in 2017 did the Federal Nursing Council issued a resolution with the areas in which this professional works.(¹1. Felipe HR, Cunha M, Ribeiro VS, Zamarioli CM, Santos CB, Duarte JC, et al. Questionário de Conhecimentos sobre Práticas de Enfermagem Forenses: adaptação para o Brasil e a propriedades psicométricas. Rev Enferm Ref. 2019;4(23):99–110.)

FN has a relevant social role and brings new possibilities for nursing practice, enabling the development of additional skills that allow nurses to intervene in situations of violence within the scope of the Unified Health System (SUS – Sistema Único de Saúde) and in the context of deprivation of liberty.(³3. Pereira de Paiva MH, Pinheiro Lages L, Cavalcanti de Medeiros Z. Studies on forensic nursing in Brazil: a systematic review of the literature. Int Nurs Rev. 2017;64(2):286-95. Review.)

Forensic nurses can act in cases of violence in different areas and life cycles. Among the areas of activity, we can mention cases of ill-treatment, trauma, death investigation, consulting, sexual violence, prison, psychiatric situations, preservation of traces and mass disasters.(²2. International Association of Forensic Nurses (IAFN). History of the Association. Elkridge: IAFN; 2018 [cited 2021 Feb 21]. Available from: https://www.forensicnurses.org/page/AboutUS
https://www.forensicnurses.org/page/Abou... )

Its area of activity is wide and becomes indispensable for the provision of care to victims of violence, since professional nurses are often the first to assist victims of violence in the health service.(⁴4. Santos AA, Silva JF, Ferreira MB, Conceição VL, Alves DM. Estado da arte da Enfermagem Forense no cenário atual da saúde. Rev Eletrônica Acervo Saúde. 2019;27:e1015.) Moreover, violence is a growing problem over the years and involves social, economic, political and cultural issues.(⁵5. Associação Brasileira de Enfermagem Forense (ABEFORENSE). Cartilha de Orientação de Enfermagem Forense. Violência, identifique, notifique, denuncie. Aracaju: ABEFORENSE; 2017. 56 p.) As it is a systemic phenomenon, violence has a direct impact on health, safety and social security systems, negatively interfering in people’s quality of life; therefore, the development of FN in the country can contribute to improving victims’ quality of life, in addition to preventing situations of violence.(⁶6. Castro VC, Rissardo LK, Carreira L. Violence against the Brazilian elderlies: an analysis of hospitalizations. Rev Bras Enferm. 2018;71(Suppl 2):777–85.)

FN can also assist in the promotion of a culture of peace and in the prevention of cases of violence, through planning educational actions aimed at professionals, but also the community in general, which may include victims and offenders, in order to disseminate knowledge about identifying signs and symptoms of violence, strengthening family bonds, establishing healthy relationships, strengthening intergenerationality, providing information on the care network for victims of violence with respective telephone contacts and websites, reporting mechanisms as well as such as adequate care for victims and conducting cases with appropriate referrals.

Another important aspect to support the rise of FN practice in Brazil is the fact that the country’s population has aged rapidly; concomitantly with this, there is an increase in violence against people aged 60 or over, and at some point these people will need to be treated at some health facility.(³3. Pereira de Paiva MH, Pinheiro Lages L, Cavalcanti de Medeiros Z. Studies on forensic nursing in Brazil: a systematic review of the literature. Int Nurs Rev. 2017;64(2):286-95. Review.) The World Health Organization (WHO) highlights that the number of older adults who suffer some type of violence is worrisome, with one in six older adults worldwide. Furthermore, elder abuse (EA) is poorly diagnosed and reported.(⁷7. Yon Y, Mikton CR, Gassoumis ZD, Wilber KH. Elder abuse prevalence in community settings: a systematic review and meta-analysis. Lancet Glob Health. 2017;5(2):e147-56. Review.) This may be related to the lack of professional training, fear and complexity in identifying EA cases.(⁸8. Phelan A, McCarthy S, McKee J. Safeguarding staff’s experience of cases of financial abuse. Br J Soc Work. 2018;48(4):924–42.)

In the suspicion or confirmation of violence, the case must be notified and health professionals must refer the cases to the Public Prosecutor’s Office, police authority, or Elder Council.(⁹9. Garbin CA, Dias IA, Rovida TA, Garbin AJ. Desafıos do profıssional de saúde na notifıcação da violência: obrigatoriedade, efetivação e encaminhamento. Ciên Saúde Coletiva. 2015;20(6):1879–90.) The identification of EA is of an emergency nature, considering that older adults attend a health service, and it may be the only chance to identify a situation of violence.(¹⁰10. Camacho AC, Alves RR. Mistreatment against the elderly in the nursing perspective: an integrative review. J Nurs UFPE Online. 2015;9(2):927–35.) Violence results in physical, psychological, financial, partner problems, functional disability and even death.(¹¹11. Santos FD, de Lima Saintrain MV, de Souza Vieira LJ, Gomes Marques Sampaio E. Characterization and prevalence of elder abuse in Brazil. J Interpers Violence. 2018 Jun 1:886260518781806.)

Thus, nurses become an intermediary in the identification of EA because it is difficult to detect, requiring an accurate look to perceive the warning signs. These are often camouflaged in recurrent accidents or pain.(⁵5. Associação Brasileira de Enfermagem Forense (ABEFORENSE). Cartilha de Orientação de Enfermagem Forense. Violência, identifique, notifique, denuncie. Aracaju: ABEFORENSE; 2017. 56 p.) Authors point out that, in order to identify situations of violence, strategies should be used for their detection, using validated instruments, qualified listening in nursing consultations, and acting in the dissemination of information about violence.(⁶6. Castro VC, Rissardo LK, Carreira L. Violence against the Brazilian elderlies: an analysis of hospitalizations. Rev Bras Enferm. 2018;71(Suppl 2):777–85.)

The commitment of nursing professionals who use of the knowledge of EA to detect violence can contribute to humanized care to the extent that interventions can break the cycle of violence. These interventions should be individualized and based on scientific evidence, in a planned way, according to current legislation, public health policies and basic nursing instruments in order to mitigate the injuries perpetrated to victims of violence.(⁵5. Associação Brasileira de Enfermagem Forense (ABEFORENSE). Cartilha de Orientação de Enfermagem Forense. Violência, identifique, notifique, denuncie. Aracaju: ABEFORENSE; 2017. 56 p.)

No similar review in progress was identified in PROSPERO, MEDLINE, cochrane systematic reviews and systematic reviews database and implementation reports of the Joanna Briggs Institute, the present study is justified and aims to describe FN care for older adults in situations of violence.

Methods

This is a scoping review guided by the methodological guidelines proposed by the Joanna Briggs Institute (JBI), considering the PRISMA-ScR initiative.(¹²12. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467-73.) The scoping review (scoping review or scoping study) aims to map the main concepts used in a given area of knowledge and identify gaps in existing evidence. (¹³13. Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 2015;13(3):141-6.)

To construct the guiding question, PCC strategy was used, being “P” for Population - nurses, “C” for Concept – elder care, and “C” for Context - violence, based on this information, the following question arose: what is FN care for older adults in situations of violence? This care was assessed by the description of the practice pointed out in studies and performed by these professionals, verifying whether practices considered forensic are related.

Studies addressing care for older adults in situations of violence performed by nurses in general were eligible, with the care of selecting those actions that could/should be performed with greater care and technical competence by forensic nurses in Brazilian English, Spanish, Portuguese and French, available fully between 1990 and 2019, this time interval is justified because it is the period of foundation of the International Association of Forensic Nursing, in 1990. It is noteworthy that studies that included nurses in the sample were considered, although other professionals were also included in the study. However, only the data regarding nurses’ answers were characterized as results for this review.

The survey of studies in literature was done between February and April 2020 by two researchers, independently. Initially, a research was carried out using the keywords elderly, nursing care and violence in two databases: MEDLINE via PubMed and CINAHL via EBSCO. At this moment, the words components of titles, abstracts and descriptors were analyzed. Studies that met the objective were read in full and had their references analyzed. Through this first investigation, the search strategies implemented to trace the documents that met the objective of the review were elaborated.

The following keywords and descriptors combined by Boolean operators AND and OR were used: ((“Nurses” OR “Forensic nursing” OR “Nurse examiner” OR “Forensic examination” OR “Nurse’s role” OR “Nursing Role” OR “Care nurse” OR “Nursing care” OR “Forensic nurse” OR “Investigating forensic nursing” OR “Sexual assault nurse examiners”) AND (“Elder” OR “Aged” OR “Elderly “ OR “Older” OR “Older adults”) AND (“Abuse” OR “Violence” OR “Sexual violence” OR “Mistreatment” OR “Sexual assault” OR “Abused” OR “Traumatic injuries” OR “Victims of violence” OR “Domestic violence” OR “Neglect” OR “Crime” OR “Strangulation” OR “Exploitation” OR “Interpersonal violence” OR “Intimidation” OR “Financial abuse”)).

The above strategy was used in the following databases: MEDLINE via PubMed, CINAHL via EBSCO and Web of Science platform. For the other databases and platforms, the following search tactics were applied: Nurse Care AND Elderly AND abuse and ((“Nurse” OR “Forensic nursing” OR “Nursing care”) AND (“Elder” OR “Aged” OR “Elderly”) AND (“Abuse” OR “violence”)). In bases that required some adequacy, the Descriptors in Health Sciences (DeCs) were also used, mainly in Portuguese-speaking bases, implementing the following strategy: nursing care and elderly and violence.

The following databases were included in this scoping review: MEDLINE via PubMed, CINAHL via EBSCO, LILACS, Embase, Scopus, PsycINFO, JBI Database of Systematic Reviews and Implementation Reports, Cochrane platforms (controlled trials and systematic reviews), and Web of Science. The gray literature search included: MedNar, Capes Theses and Dissertationportal, DART European Portal of E-Theses, Theses Canada, Google Academic and Center for Nursing Studies and Research - CEPEN.

In the databases, initially, 17,378 studies were identified after reading the titles; 140 were selected because they suggested discussing nurses’ care in cases of EA, and went on to the stage of exhaustive evaluation of all abstracts, 29 really addressed nurses’ performance regarding older adults in a situation of violence, and passed to the stage of reading the full text, of these, 18 met the purpose of the review. After analysis of references, a study was included, totaling 19 documents, as presented in the PRISMA-ScR flowchart adaptation(¹²12. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467-73.) (Figure 1).

Figure 1
Flowchart of the selection process of studies adapted from PRISMA

Data were extracted using a data extraction instrument developed by the reviewers, which included specific details about the care of nurses for older adults in situations of violence, difficulties reported by nurses, in addition to metadata (authorship, methodological approach, level of health care, country, year of publication, database and type of publication).

The care provided by nurses was categorized into prevention measures, resources used, interventions, referrals, complaints and difficulties reported by nurses to provide care for older adults in situations of violence. These were categorized into organizational problems, professional training, and personal issues.

Results

Study characteristic

The type of publication was predominantly articles in English (73.7%). Five articles were in Brazilian Portuguese. The prevalence of studies with a qualitative approach (73.7%) stands out, followed by quantitative studies (26.3%).

Regarding the country of origin, the majority was in Brazil (26.3%), followed by Australia and the United States of America (USA), with (15.8%) respectively, Israel with (10.5%) of publications, Ireland, South Korea, Iran, Switzerland, Japan, Canada with (5.2%) publications. Regarding the level of health care in which nurses work, Primary Care predominated (36.8%) followed by hospital and home care (31.6%). The type of violence most addressed in the studies was general violence (84.2%). The metadata of studies is presented in Chart 1.

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Chart 1
Characterization of publications

Forensic nursing care

Care for older adults in situation of violence carried through for nurses in the whole world varies between the continents and was separate for category for better understanding and meets in Chart 2 described.

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Chart 2
Care for older adults in violence situation carried through for nurses in agreement story of the studies

Difficulties reported by nurses to provide care

In most studies eligible for this review (n=18; 90%), nurses reported difficulties in providing care to older adults in situations of violence (Chart 3).

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Chart 3
Difficulties reported by nurses when providing care to older adults in situations of violence as described in the studies

Discussion

Among the studies selected for this review, some have exposed the measures to prevent EA reported by the nurses who participated in the respective studies. In Australia, nurses monitor offenders to prevent new cases of EA from happening.(¹⁴14. Cairns J, Vreugdenhil A. Working at the frontline in cases of elder abuse: ‘it keeps me awake at night’. Australas J Ageing. 2014;33(1):59-62.) In Norway and Australia, nurses accompany older adults to prevent EA from occurring.(²³23. Sandmoe A, Kirkevold M, Ballantyne A. Challenges in handling elder abuse in community care. An exploratory study among nurses and care coordinators in Norway and Australia. J Clin Nurs. 2011;20(23-24):3351-63.) Additionally, in Norway and Australia, nurses supervise caregivers in their daily life, and when there is no improvement in the care process, they suggest that caregivers be removed from the function and requests home care for older adults. Furthermore, nurses protect older adults against influences that influence them to prevent them from leaving the cycle of violence and develop safety plans to prevent abuse. (²³23. Sandmoe A, Kirkevold M, Ballantyne A. Challenges in handling elder abuse in community care. An exploratory study among nurses and care coordinators in Norway and Australia. J Clin Nurs. 2011;20(23-24):3351-63.)

A systematic review on the factors associated with EA, demonstrated that when the elderly are dependent on activities of daily living; and instrumental, the caregiver overloads, and consequently increases the possibility of the elderly suffering general and financial violence.(³²32. Santos MA, Moreira RS, Faccio PF, Gomes GC, Silva VL. Factors associated with elder abuse: a systematic review of the literature. Ciên Saúde Coletiva. 2020;25(6):2153–75.)

In Norway, daily customer visits are a strategy used to reduce caregivers’ stress and workload or reduce dependence on offenders’ older client. Moreover, they transfer victims to Nursing Homes (NHs) when necessary. Nurses from Switzerland and Japan also conduct home visits to assess the domestic environment as a measure to prevent violence. These strategies are relevant when considering the number of cases of domestic elder abuse. A study conducted in the city of Recife, Pernambuco, Brazil, with the objective of investigating the prevalence of domestic elder abuse, shows that 78.7% of older adults, among the 169 investigated, report having suffered some type of violence, and negligence is prevalent, followed by psychological and financial violence.(³³33. Barros RL, Leal MC, Marques AP, Lins ME. Domestic violence against elderly people assisted in primary care. Saúde Debate. 2019;43(122):793–804.)

Many older adults need third-party care, and if they suffer some kind of violence at home, the visit may be the only opportunity to prevent or identify situations of violence. Once, vulnerability increases with the burden and unpreparedness of family members and caregivers.(¹⁵15. Oliveira KS, Carvalho FP, Oliveira LC, Simpson CA, Silva FT, Martins AG. Violência contra idosos: concepções dos profissionais de enfermagem acerca da detecção e prevenção. Rev Gaúcha Enferm. 2018;39:e57462.)

In Iran and Brazil, nurses use educational actions for the education of older adults and family members, in order to prevent and combat cases of elder abuse as evidenced in the results of this scoping review. These actions and the aforementioned are considered FN practices as described in COFEN Resolution 0556/2017.(³⁴34. Conselho Federal de Enfermagem (COFEN). Resolução COFEN nº. 556/2017. Brasília (DF): COFEN; 2017 [citado 2021 Fev 21]. Disponível em: http://www.cofen.gov.br/resolucao-cofen-no-05562017_54582.html
http://www.cofen.gov.br/resolucao-cofen-... )

When it comes to the resources to identify cases of EA, nurses in Norway used techniques applied by FN, such as interview, clinical assessment, and home visit.(²²22. Sandmoe A, Kirkevold M. Nurses’ clinical assessments of older clients who are suspected victims of abuse: an exploratory study in community care in Norway. J Clin Nurs. 2011;20(1-2):94-102.) In Switzerland, Japan, Canada and Australia, the interview was also a resource used by nurses.(²⁹29. Erlingsson C, Ono M, Sasaki A, Saveman BI. An international collaborative study comparing Swedish and Japanese nurses’ reactions to elder abuse. J Adv Nurs. 2012;68(1):56-68.,³¹31. Trevitt C, Gallagher E. Elder abuse in Canada and Australia: implications for nurses. Int J Nurs Stud. 1996;33(6):651-9.) Anamnesis and physical examination are also a strategy applied by nurses in Brazil.(¹⁶16. Musse JO, Rios MH. Atuação do enfermeiro perante a violência doméstica sofrida pelo idoso. Estud Interdiscip Envelhec. 2015;20(2):365–79.) In the USA, a form for assessing violence and clinical investigation is used.(¹⁹19. Miller CA. Elder Abuse. The nurse’s perspective. Clin Gerontol. 2005;28(1–2):105–33.,²⁵25. Daly JM, Schmeidel Klein AN, Jogerst GJ. Critical care nurses’ perspectives on elder abuse. Nurs Crit Care. 2012;17(4):172-9.)

The observation of older adults’ behavior, postural communication, facial expression, combined with qualified listening, can allow the identification of vulnerable situations, and from this, it is possible to develop appropriate strategies to face EA.(⁶6. Castro VC, Rissardo LK, Carreira L. Violence against the Brazilian elderlies: an analysis of hospitalizations. Rev Bras Enferm. 2018;71(Suppl 2):777–85.)

All these resources are essential tools to identify situations of violence; however, it has its particularities to depend on the uniqueness of each case. It can be cited, as an example, the interview (part of the nursing process) may not be applied in an older adult who does not communicate, on the other hand, physical examination may be effective to identify signs suggestive of violence. When it comes to physical violence, physical examination may be the best strategy for identification, especially when there are bruising and evident traumas. In this regard, many older adults seek urgency with signs of burns, fractures, and other physical damage.(³⁵35. Pillemer K, Burnes D, Riffin C, Lachs MS. Elder Abuse: Global Situation, Risk Factors, and Prevention Strategies. Gerontologist. 2016;(Suppl 2):S194-205. Review.) It is important to perform a quality anamnesis to identify the causes of the injuries.

Regarding the interventions performed by nurses, in Brazil, these interventions are directed to the investigation of cases as well as in Canada and Australia. Welcoming victims of violence and dialoguing with offenders’ families are carried out by nurses from Brazil, Australia, Norway, Iran, Switzerland, and Japan.(¹⁴14. Cairns J, Vreugdenhil A. Working at the frontline in cases of elder abuse: ‘it keeps me awake at night’. Australas J Ageing. 2014;33(1):59-62.,¹⁷17. Azevedo CO, Silva TA. Cuidados de enfermagem para detecção de violência contra idosos. Rev Pró-UniverSUS. 2019;10(1):55–9.,²³23. Sandmoe A, Kirkevold M, Ballantyne A. Challenges in handling elder abuse in community care. An exploratory study among nurses and care coordinators in Norway and Australia. J Clin Nurs. 2011;20(23-24):3351-63.,²⁶26. Alipour A, Fotokian Z, Shamsalinia A, Ghaffari F, Hajiahmadi M. The relationship between nurses’ recognition regarding elder abuse and their attitudes and performance in dealing with elder abuse induced by iranian family caregivers. Open Nurs J. 2019;13(1):116–22.,²⁹29. Erlingsson C, Ono M, Sasaki A, Saveman BI. An international collaborative study comparing Swedish and Japanese nurses’ reactions to elder abuse. J Adv Nurs. 2012;68(1):56-68.)

In Brazil, nurses discuss the case of EA with the team, with the social service and elder health coordinator, and also records the case in the medical records. In the USA, emotional and professional resources are a strategy adopted by nurses to try to solve the case. Corrective measures are used by nurses in Australia and Norway, but studies do not specify them. Studies carried out in Israel and Iran, respectively, reveal neutral attitudes of nurses in relation to intervening in cases of EA.(¹⁶16. Musse JO, Rios MH. Atuação do enfermeiro perante a violência doméstica sofrida pelo idoso. Estud Interdiscip Envelhec. 2015;20(2):365–79.,¹⁸18. Almogue A, Weiss A, Marcus EL, Beloosesky Y. Attitudes and knowledge of medical and nursing staff toward elder abuse. Arch Gerontol Geriatr. 2010;51(1):86-91.) It characterizes an approach not consistent with the role of nurses as active in the health and disease process. In Brazil, if this occurs, nurses can be punished according to law, as it is “everyone’s duty to prevent the threat or violation of elder rights”, according to Law 10.741/2003.( ³⁶36. Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei no 10.741, de 1º de outubro de 2003. Dispõe sobre o Estatuto do Idoso e dá outras providências. Brasília (DF): Presidência da República; 2003. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/2003/l10.741.htm
http://www.planalto.gov.br/ccivil_03/lei... )

In this regard, identifying situations of vulnerability in which older adults are a complex task; therefore, a holistic and singular approach should be considered. A study conducted in the city of Recife-PE, with 169 older adults, revealed that neglect was the most prevalent type of violence, representing 58.5% of the cases, followed by financial violence 21.5% and psychological violence 14.0%.(³³33. Barros RL, Leal MC, Marques AP, Lins ME. Domestic violence against elderly people assisted in primary care. Saúde Debate. 2019;43(122):793–804.) All of these, which may occur in the family environment, which makes it difficult to identify and prevent cases. Thus, home visits can be an applicable resource to assist in the identification of cases of EA.

Regarding the referral of EA cases, nurses refer to the different professionals who compose the multidisciplinary team and, when necessary, direct to hospitals and competent bodies. Forwarding to social services was reported in five studies, conducted in Brazil, USA, Norway, and Iran.¹⁷17. Azevedo CO, Silva TA. Cuidados de enfermagem para detecção de violência contra idosos. Rev Pró-UniverSUS. 2019;10(1):55–9.,¹⁹19. Miller CA. Elder Abuse. The nurse’s perspective. Clin Gerontol. 2005;28(1–2):105–33.,²³23. Sandmoe A, Kirkevold M, Ballantyne A. Challenges in handling elder abuse in community care. An exploratory study among nurses and care coordinators in Norway and Australia. J Clin Nurs. 2011;20(23-24):3351-63.

The referral of cases of violence to other instances is elementary to continue the case resolution. However, a study conducted in the municipality of Goiânia-GO, with the objective of analyzing the profile of older adults victims of violence assisted in an emergency hospital, within one year, revealed that there was no articulation and communication between the specialized institutions to which they were referred, thus interrupting care.(³⁷37. Soares MC, Barbosa AM. Perfil de idosos vítimas de violência atendidos em um hospital de urgências. Rev Cient Esc Saúde Pública Goiás “Candido Santiago”. 2020;6(1):18–34.)

Regarding complaints and reporting of cases of EA, in Brazil, nurses denounce the competent bodies, such as the Elder Council, the Human Rights Office and police. Additionally, they notify in SINAN. The complaint to the competent bodies was reported in a single study conducted in the USA.(¹⁹19. Miller CA. Elder Abuse. The nurse’s perspective. Clin Gerontol. 2005;28(1–2):105–33.)The complaint specifically to the police was also reported in studies conducted in Norway, Australia, and Iran.(²³23. Sandmoe A, Kirkevold M, Ballantyne A. Challenges in handling elder abuse in community care. An exploratory study among nurses and care coordinators in Norway and Australia. J Clin Nurs. 2011;20(23-24):3351-63.,²⁴24. Sandmoe A, Kirkevold M. Identifying and handling abused older clients in community care: the perspectives of nurse managers. Int J Older People Nurs. 2013;8(2):83-92.,²⁶26. Alipour A, Fotokian Z, Shamsalinia A, Ghaffari F, Hajiahmadi M. The relationship between nurses’ recognition regarding elder abuse and their attitudes and performance in dealing with elder abuse induced by iranian family caregivers. Open Nurs J. 2019;13(1):116–22.)

In recent years, Brazil has invested in policies that aim to combat violence. In 2001, the Ministry of Health instituted the Brazilian National Policy for Reducing Morbidity and Mortality from Accidents and Violence (Política Nacional de Redução a Morbimortalidade por Acidentes e Violências); in addition, an instructional manual was published guiding the completion of a notification form for cases of violence.(³⁸38. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde. Viva: instrutiva notificação de violência interpessoal e autoprovocada. 2a ed. Brasília (DF): Ministério da Saúde; 2016. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/viva_instrutivo_violencia_interpessoal_autoprovocada_2ed.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ) In 2011, with Law 12,461, compulsory notification of cases of EA became mandatory by all health professionals working in public or private services in Brazil.(³⁹39. Brasil. Câmara dos Deputados. Lei no 12.461, de 26 de julho de 2011. Altera a Lei no 10.741, de 1o de outubro de 2003, para estabelecer a notificação compulsória dos atos de violência praticados contra o idoso atendido em serviço de saúde. Brasília (DF): Câmara dos Deputados; 2011. Disponível em: https://www2.camara.leg.br/legin/fed/lei/2011/lei-12461-26-julho-2011-611103-norma-pl.html
https://www2.camara.leg.br/legin/fed/lei... ) Also, this same law brings the obligation to report cases of EA, “to any of the following bodies: police authority, public prosecutor, municipal elder council, Elder State Council, and /or National Elder Council”.

Nurses report the difficulties in acting in situations of EA, whether personal, professional and even infrastructure to prevent cases and/or to assist the victims perpetrated. In addition to this, theabsenceof educational programs in the services to improve the performance of nurses at different levels of Prevention of EA.(²⁶26. Alipour A, Fotokian Z, Shamsalinia A, Ghaffari F, Hajiahmadi M. The relationship between nurses’ recognition regarding elder abuse and their attitudes and performance in dealing with elder abuse induced by iranian family caregivers. Open Nurs J. 2019;13(1):116–22.,²⁷27. Almeida CA, Silva Neto MC, Carvalho FM, Lago EC. Aspectos relacionados à violência contra o idoso: concepção do enfermeiro da estratégia saúde da família. J Res Fundam Care Online. 2019;11(Esp):404–10.)

Nurses are insecure when handling EA situations due to lack of clear guidance on how to define and manage abuse within trust relationships, and because they feel fragility in legislation.(⁸8. Phelan A, McCarthy S, McKee J. Safeguarding staff’s experience of cases of financial abuse. Br J Soc Work. 2018;48(4):924–42.) Also, the lack of support from the health department and other municipal departments, the absence of professional cooperation, responsibility, lack of training, lack of capacity to act in some cases, the procedures of notification, detection and intervention are obstacles that impact coping with EA.(¹⁵15. Oliveira KS, Carvalho FP, Oliveira LC, Simpson CA, Silva FT, Martins AG. Violência contra idosos: concepções dos profissionais de enfermagem acerca da detecção e prevenção. Rev Gaúcha Enferm. 2018;39:e57462.)

Similarly, the various factors intrinsic to the elderly contribute to hinder the identification of violence by nurses, such as fear, shame and omission for fear of offenders or for not wanting to denounce them for issues of parental affinities.(¹⁷17. Azevedo CO, Silva TA. Cuidados de enfermagem para detecção de violência contra idosos. Rev Pró-UniverSUS. 2019;10(1):55–9.) A dilemma arises that refers to elder right to choose how to live their lives versus the desire and obligation of nurses to help and perform their professional functions.(²⁰20. Band-Winterstein T. Nurses’ encounters with older adults engaged in self-neglectful behaviors in the community: a qualitative study. J Appl Gerontol. 2018;37(8):965-89.)

It is noteworthy that the actions of generalist nurses, evidenced in the present study, are in line with FN practices, recommended by Resolution COFEN 556/2017, which involve: reporting cases of violence to authorities, planning interviews, the need involving other professionals and family members, identifying traces of criminal relevance, identifying indicators of suspected violence, documenting all relevant information, coordinating the victim’s transition between care settings, guiding access to legal resources, involving other professionals to ensure continuity of care, use interview techniques, observe the behavior of the victim and others involved, among others. (³⁴34. Conselho Federal de Enfermagem (COFEN). Resolução COFEN nº. 556/2017. Brasília (DF): COFEN; 2017 [citado 2021 Fev 21]. Disponível em: http://www.cofen.gov.br/resolucao-cofen-no-05562017_54582.html
http://www.cofen.gov.br/resolucao-cofen-... )

The challenges in dealing with situations of violence are numerous, so the expansion of EA should be encouraged around the world. By allowing complete assistance to victims, perpetrators and family members, using screening tools as mentioned above for early detection and implementation of systematized nursing care,(²2. International Association of Forensic Nurses (IAFN). History of the Association. Elkridge: IAFN; 2018 [cited 2021 Feb 21]. Available from: https://www.forensicnurses.org/page/AboutUS
https://www.forensicnurses.org/page/Abou... ) allowing to maintain a record of all information, as it can be considered as evidence in lawsuits and legal support of health professionals.

The study limitations are absence of publications specifically involving forensic nurses.

Conclusion

Nurses use diversified strategies depending on the context of violence and the country they act on. It is possible to perceive forensic care in the actions of generalist nurses, although they do not necessarily have the knowledge that they are using strategies that are part of the specialty. Studies show that nurses support older adults victims of violence investigate cases through clinical assessment, report to the authorities and activate the multidisciplinary team in an attempt to solve the problem. However, these professionals find barriers to identify and manage older adults in situations of violence, since it is a complex phenomenon that is difficult to detect. Among these barriers are lack of management support, the inability to identify situations of violence, the lack of training and the absence of public policies. In this sense, the results found may provide subsidies to plan the rise of FN, and qualification of generalist professionals, based on this knowledge, consequently promoting efficient assistance to these victims and improving their quality of life.

Acknowledgments

This work was carried out with the support of the Brazilian National Council for Scientific and Technological Development (CNPq - Conselho Nacional de Desenvolvimento Científico e Tecnológico) through the Universal Call MCTIC/CNPq 2018 and the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) - Funding Code 001.

Referências

¹
Felipe HR, Cunha M, Ribeiro VS, Zamarioli CM, Santos CB, Duarte JC, et al. Questionário de Conhecimentos sobre Práticas de Enfermagem Forenses: adaptação para o Brasil e a propriedades psicométricas. Rev Enferm Ref. 2019;4(23):99–110.
²
International Association of Forensic Nurses (IAFN). History of the Association. Elkridge: IAFN; 2018 [cited 2021 Feb 21]. Available from: https://www.forensicnurses.org/page/AboutUS
» https://www.forensicnurses.org/page/AboutUS
³
Pereira de Paiva MH, Pinheiro Lages L, Cavalcanti de Medeiros Z. Studies on forensic nursing in Brazil: a systematic review of the literature. Int Nurs Rev. 2017;64(2):286-95. Review.
⁴
Santos AA, Silva JF, Ferreira MB, Conceição VL, Alves DM. Estado da arte da Enfermagem Forense no cenário atual da saúde. Rev Eletrônica Acervo Saúde. 2019;27:e1015.
⁵
Associação Brasileira de Enfermagem Forense (ABEFORENSE). Cartilha de Orientação de Enfermagem Forense. Violência, identifique, notifique, denuncie. Aracaju: ABEFORENSE; 2017. 56 p.
⁶
Castro VC, Rissardo LK, Carreira L. Violence against the Brazilian elderlies: an analysis of hospitalizations. Rev Bras Enferm. 2018;71(Suppl 2):777–85.
⁷
Yon Y, Mikton CR, Gassoumis ZD, Wilber KH. Elder abuse prevalence in community settings: a systematic review and meta-analysis. Lancet Glob Health. 2017;5(2):e147-56. Review.
⁸
Phelan A, McCarthy S, McKee J. Safeguarding staff’s experience of cases of financial abuse. Br J Soc Work. 2018;48(4):924–42.
⁹
Garbin CA, Dias IA, Rovida TA, Garbin AJ. Desafıos do profıssional de saúde na notifıcação da violência: obrigatoriedade, efetivação e encaminhamento. Ciên Saúde Coletiva. 2015;20(6):1879–90.
¹⁰
Camacho AC, Alves RR. Mistreatment against the elderly in the nursing perspective: an integrative review. J Nurs UFPE Online. 2015;9(2):927–35.
¹¹
Santos FD, de Lima Saintrain MV, de Souza Vieira LJ, Gomes Marques Sampaio E. Characterization and prevalence of elder abuse in Brazil. J Interpers Violence. 2018 Jun 1:886260518781806.
¹²
Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467-73.
¹³
Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 2015;13(3):141-6.
¹⁴
Cairns J, Vreugdenhil A. Working at the frontline in cases of elder abuse: ‘it keeps me awake at night’. Australas J Ageing. 2014;33(1):59-62.
¹⁵
Oliveira KS, Carvalho FP, Oliveira LC, Simpson CA, Silva FT, Martins AG. Violência contra idosos: concepções dos profissionais de enfermagem acerca da detecção e prevenção. Rev Gaúcha Enferm. 2018;39:e57462.
¹⁶
Musse JO, Rios MH. Atuação do enfermeiro perante a violência doméstica sofrida pelo idoso. Estud Interdiscip Envelhec. 2015;20(2):365–79.
¹⁷
Azevedo CO, Silva TA. Cuidados de enfermagem para detecção de violência contra idosos. Rev Pró-UniverSUS. 2019;10(1):55–9.
¹⁸
Almogue A, Weiss A, Marcus EL, Beloosesky Y. Attitudes and knowledge of medical and nursing staff toward elder abuse. Arch Gerontol Geriatr. 2010;51(1):86-91.
¹⁹
Miller CA. Elder Abuse. The nurse’s perspective. Clin Gerontol. 2005;28(1–2):105–33.
²⁰
Band-Winterstein T. Nurses’ encounters with older adults engaged in self-neglectful behaviors in the community: a qualitative study. J Appl Gerontol. 2018;37(8):965-89.
²¹
Ko C, Koh CK. Factors related to korean nurses’ Willingness to report suspected elder abuse. Asian Nurs Res (Korean Soc Nurs Sci). 2012;6(3):115-9.
²²
Sandmoe A, Kirkevold M. Nurses’ clinical assessments of older clients who are suspected victims of abuse: an exploratory study in community care in Norway. J Clin Nurs. 2011;20(1-2):94-102.
²³
Sandmoe A, Kirkevold M, Ballantyne A. Challenges in handling elder abuse in community care. An exploratory study among nurses and care coordinators in Norway and Australia. J Clin Nurs. 2011;20(23-24):3351-63.
²⁴
Sandmoe A, Kirkevold M. Identifying and handling abused older clients in community care: the perspectives of nurse managers. Int J Older People Nurs. 2013;8(2):83-92.
²⁵
Daly JM, Schmeidel Klein AN, Jogerst GJ. Critical care nurses’ perspectives on elder abuse. Nurs Crit Care. 2012;17(4):172-9.
²⁶
Alipour A, Fotokian Z, Shamsalinia A, Ghaffari F, Hajiahmadi M. The relationship between nurses’ recognition regarding elder abuse and their attitudes and performance in dealing with elder abuse induced by iranian family caregivers. Open Nurs J. 2019;13(1):116–22.
²⁷
Almeida CA, Silva Neto MC, Carvalho FM, Lago EC. Aspectos relacionados à violência contra o idoso: concepção do enfermeiro da estratégia saúde da família. J Res Fundam Care Online. 2019;11(Esp):404–10.
²⁸
Rocha EN, Vilela AB, Silva DM. Enfrentamento da violência intrafamiliar contra pessoas idosas pelos profissionais de saúde. Kairós Gerontol. 2015;18(4):29–46.
²⁹
Erlingsson C, Ono M, Sasaki A, Saveman BI. An international collaborative study comparing Swedish and Japanese nurses’ reactions to elder abuse. J Adv Nurs. 2012;68(1):56-68.
³⁰
Johnson YO. Home care nurses’ experiences with and perceptions of elder self-neglect. Home Healthc Now. 2015;33(1):31-7.
³¹
Trevitt C, Gallagher E. Elder abuse in Canada and Australia: implications for nurses. Int J Nurs Stud. 1996;33(6):651-9.
³²
Santos MA, Moreira RS, Faccio PF, Gomes GC, Silva VL. Factors associated with elder abuse: a systematic review of the literature. Ciên Saúde Coletiva. 2020;25(6):2153–75.
³³
Barros RL, Leal MC, Marques AP, Lins ME. Domestic violence against elderly people assisted in primary care. Saúde Debate. 2019;43(122):793–804.
³⁴
Conselho Federal de Enfermagem (COFEN). Resolução COFEN nº. 556/2017. Brasília (DF): COFEN; 2017 [citado 2021 Fev 21]. Disponível em: http://www.cofen.gov.br/resolucao-cofen-no-05562017_54582.html
» http://www.cofen.gov.br/resolucao-cofen-no-05562017_54582.html
³⁵
Pillemer K, Burnes D, Riffin C, Lachs MS. Elder Abuse: Global Situation, Risk Factors, and Prevention Strategies. Gerontologist. 2016;(Suppl 2):S194-205. Review.
³⁶
Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei n^o 10.741, de 1º de outubro de 2003. Dispõe sobre o Estatuto do Idoso e dá outras providências. Brasília (DF): Presidência da República; 2003. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/2003/l10.741.htm
» http://www.planalto.gov.br/ccivil_03/leis/2003/l10.741.htm
³⁷
Soares MC, Barbosa AM. Perfil de idosos vítimas de violência atendidos em um hospital de urgências. Rev Cient Esc Saúde Pública Goiás “Candido Santiago”. 2020;6(1):18–34.
³⁸
Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde. Viva: instrutiva notificação de violência interpessoal e autoprovocada. 2a ed. Brasília (DF): Ministério da Saúde; 2016. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/viva_instrutivo_violencia_interpessoal_autoprovocada_2ed.pdf
» http://bvsms.saude.gov.br/bvs/publicacoes/viva_instrutivo_violencia_interpessoal_autoprovocada_2ed.pdf
³⁹
Brasil. Câmara dos Deputados. Lei n^o 12.461, de 26 de julho de 2011. Altera a Lei n^o 10.741, de 1^o de outubro de 2003, para estabelecer a notificação compulsória dos atos de violência praticados contra o idoso atendido em serviço de saúde. Brasília (DF): Câmara dos Deputados; 2011. Disponível em: https://www2.camara.leg.br/legin/fed/lei/2011/lei-12461-26-julho-2011-611103-norma-pl.html
» https://www2.camara.leg.br/legin/fed/lei/2011/lei-12461-26-julho-2011-611103-norma-pl.html

Publication Dates

Publication in this collection
26 Nov 2021
Date of issue
2021

History

Received
29 Aug 2020
Accepted
16 Mar 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

[1] ¹
Felipe HR, Cunha M, Ribeiro VS, Zamarioli CM, Santos CB, Duarte JC, et al. Questionário de Conhecimentos sobre Práticas de Enfermagem Forenses: adaptação para o Brasil e a propriedades psicométricas. Rev Enferm Ref. 2019;4(23):99–110.

[2] ²
International Association of Forensic Nurses (IAFN). History of the Association. Elkridge: IAFN; 2018 [cited 2021 Feb 21]. Available from: https://www.forensicnurses.org/page/AboutUS
» https://www.forensicnurses.org/page/AboutUS

[3] ³
Pereira de Paiva MH, Pinheiro Lages L, Cavalcanti de Medeiros Z. Studies on forensic nursing in Brazil: a systematic review of the literature. Int Nurs Rev. 2017;64(2):286-95. Review.

[4] ⁴
Santos AA, Silva JF, Ferreira MB, Conceição VL, Alves DM. Estado da arte da Enfermagem Forense no cenário atual da saúde. Rev Eletrônica Acervo Saúde. 2019;27:e1015.

[5] ⁵
Associação Brasileira de Enfermagem Forense (ABEFORENSE). Cartilha de Orientação de Enfermagem Forense. Violência, identifique, notifique, denuncie. Aracaju: ABEFORENSE; 2017. 56 p.

[6] ⁶
Castro VC, Rissardo LK, Carreira L. Violence against the Brazilian elderlies: an analysis of hospitalizations. Rev Bras Enferm. 2018;71(Suppl 2):777–85.

[7] ⁷
Yon Y, Mikton CR, Gassoumis ZD, Wilber KH. Elder abuse prevalence in community settings: a systematic review and meta-analysis. Lancet Glob Health. 2017;5(2):e147-56. Review.

[8] ⁸
Phelan A, McCarthy S, McKee J. Safeguarding staff’s experience of cases of financial abuse. Br J Soc Work. 2018;48(4):924–42.

[9] ⁹
Garbin CA, Dias IA, Rovida TA, Garbin AJ. Desafıos do profıssional de saúde na notifıcação da violência: obrigatoriedade, efetivação e encaminhamento. Ciên Saúde Coletiva. 2015;20(6):1879–90.

[10] ¹⁰
Camacho AC, Alves RR. Mistreatment against the elderly in the nursing perspective: an integrative review. J Nurs UFPE Online. 2015;9(2):927–35.

[11] ¹¹
Santos FD, de Lima Saintrain MV, de Souza Vieira LJ, Gomes Marques Sampaio E. Characterization and prevalence of elder abuse in Brazil. J Interpers Violence. 2018 Jun 1:886260518781806.

[12] ¹²
Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467-73.

[13] ¹³
Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 2015;13(3):141-6.

[14] ¹⁴
Cairns J, Vreugdenhil A. Working at the frontline in cases of elder abuse: ‘it keeps me awake at night’. Australas J Ageing. 2014;33(1):59-62.

[15] ¹⁵
Oliveira KS, Carvalho FP, Oliveira LC, Simpson CA, Silva FT, Martins AG. Violência contra idosos: concepções dos profissionais de enfermagem acerca da detecção e prevenção. Rev Gaúcha Enferm. 2018;39:e57462.

[16] ¹⁶
Musse JO, Rios MH. Atuação do enfermeiro perante a violência doméstica sofrida pelo idoso. Estud Interdiscip Envelhec. 2015;20(2):365–79.

[17] ¹⁷
Azevedo CO, Silva TA. Cuidados de enfermagem para detecção de violência contra idosos. Rev Pró-UniverSUS. 2019;10(1):55–9.

[18] ¹⁸
Almogue A, Weiss A, Marcus EL, Beloosesky Y. Attitudes and knowledge of medical and nursing staff toward elder abuse. Arch Gerontol Geriatr. 2010;51(1):86-91.

[19] ¹⁹
Miller CA. Elder Abuse. The nurse’s perspective. Clin Gerontol. 2005;28(1–2):105–33.

[20] ²⁰
Band-Winterstein T. Nurses’ encounters with older adults engaged in self-neglectful behaviors in the community: a qualitative study. J Appl Gerontol. 2018;37(8):965-89.

[21] ²¹
Ko C, Koh CK. Factors related to korean nurses’ Willingness to report suspected elder abuse. Asian Nurs Res (Korean Soc Nurs Sci). 2012;6(3):115-9.

[22] ²²
Sandmoe A, Kirkevold M. Nurses’ clinical assessments of older clients who are suspected victims of abuse: an exploratory study in community care in Norway. J Clin Nurs. 2011;20(1-2):94-102.

[23] ²³
Sandmoe A, Kirkevold M, Ballantyne A. Challenges in handling elder abuse in community care. An exploratory study among nurses and care coordinators in Norway and Australia. J Clin Nurs. 2011;20(23-24):3351-63.

[24] ²⁴
Sandmoe A, Kirkevold M. Identifying and handling abused older clients in community care: the perspectives of nurse managers. Int J Older People Nurs. 2013;8(2):83-92.

[25] ²⁵
Daly JM, Schmeidel Klein AN, Jogerst GJ. Critical care nurses’ perspectives on elder abuse. Nurs Crit Care. 2012;17(4):172-9.

[26] ²⁶
Alipour A, Fotokian Z, Shamsalinia A, Ghaffari F, Hajiahmadi M. The relationship between nurses’ recognition regarding elder abuse and their attitudes and performance in dealing with elder abuse induced by iranian family caregivers. Open Nurs J. 2019;13(1):116–22.

[27] ²⁷
Almeida CA, Silva Neto MC, Carvalho FM, Lago EC. Aspectos relacionados à violência contra o idoso: concepção do enfermeiro da estratégia saúde da família. J Res Fundam Care Online. 2019;11(Esp):404–10.

[28] ²⁸
Rocha EN, Vilela AB, Silva DM. Enfrentamento da violência intrafamiliar contra pessoas idosas pelos profissionais de saúde. Kairós Gerontol. 2015;18(4):29–46.

[29] ²⁹
Erlingsson C, Ono M, Sasaki A, Saveman BI. An international collaborative study comparing Swedish and Japanese nurses’ reactions to elder abuse. J Adv Nurs. 2012;68(1):56-68.

[30] ³⁰
Johnson YO. Home care nurses’ experiences with and perceptions of elder self-neglect. Home Healthc Now. 2015;33(1):31-7.

[31] ³¹
Trevitt C, Gallagher E. Elder abuse in Canada and Australia: implications for nurses. Int J Nurs Stud. 1996;33(6):651-9.

[32] ³²
Santos MA, Moreira RS, Faccio PF, Gomes GC, Silva VL. Factors associated with elder abuse: a systematic review of the literature. Ciên Saúde Coletiva. 2020;25(6):2153–75.

[33] ³³
Barros RL, Leal MC, Marques AP, Lins ME. Domestic violence against elderly people assisted in primary care. Saúde Debate. 2019;43(122):793–804.

[34] ³⁴
Conselho Federal de Enfermagem (COFEN). Resolução COFEN nº. 556/2017. Brasília (DF): COFEN; 2017 [citado 2021 Fev 21]. Disponível em: http://www.cofen.gov.br/resolucao-cofen-no-05562017_54582.html
» http://www.cofen.gov.br/resolucao-cofen-no-05562017_54582.html

[35] ³⁵
Pillemer K, Burnes D, Riffin C, Lachs MS. Elder Abuse: Global Situation, Risk Factors, and Prevention Strategies. Gerontologist. 2016;(Suppl 2):S194-205. Review.

[36] ³⁶
Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei n^o 10.741, de 1º de outubro de 2003. Dispõe sobre o Estatuto do Idoso e dá outras providências. Brasília (DF): Presidência da República; 2003. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/2003/l10.741.htm
» http://www.planalto.gov.br/ccivil_03/leis/2003/l10.741.htm

[37] ³⁷
Soares MC, Barbosa AM. Perfil de idosos vítimas de violência atendidos em um hospital de urgências. Rev Cient Esc Saúde Pública Goiás “Candido Santiago”. 2020;6(1):18–34.

[38] ³⁸
Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde. Viva: instrutiva notificação de violência interpessoal e autoprovocada. 2a ed. Brasília (DF): Ministério da Saúde; 2016. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/viva_instrutivo_violencia_interpessoal_autoprovocada_2ed.pdf
» http://bvsms.saude.gov.br/bvs/publicacoes/viva_instrutivo_violencia_interpessoal_autoprovocada_2ed.pdf

[39] ³⁹
Brasil. Câmara dos Deputados. Lei n^o 12.461, de 26 de julho de 2011. Altera a Lei n^o 10.741, de 1^o de outubro de 2003, para estabelecer a notificação compulsória dos atos de violência praticados contra o idoso atendido em serviço de saúde. Brasília (DF): Câmara dos Deputados; 2011. Disponível em: https://www2.camara.leg.br/legin/fed/lei/2011/lei-12461-26-julho-2011-611103-norma-pl.html
» https://www2.camara.leg.br/legin/fed/lei/2011/lei-12461-26-julho-2011-611103-norma-pl.html

Title	Year	Type of violence addressed	Health care level	Methodological approach	Country of study	Database	Publication type
Safeguarding staff’s experience of cases of financial abuse ⁽⁸⁾	2018	Financial violence	Household	Qualitative	Ireland	CINAHL	Article
Working at the frontline in cases of elder abuse: ‘It keeps me awake at night⁽¹⁴⁾	2014	Violence in general	Household	Qualitative	Australia	CINAHL	Article
Violência contra o idoso: as concepções dos profissionais de enfermagem sobre detecção e prevenção⁽¹⁵⁾	2018	Violence in general	Primary Care	Qualitative	Brazil	CINAHL	Article
Atuação do enfermeiro perante a violência doméstica sofrida pelo idoso⁽¹⁶⁾	2015	Domestic violence	Primary Care	Quantitative	Brazil	Google Scholar	Article
Cuidados de Enfermagem para detecção de violência contra idosos⁽¹⁷⁾	2019	Violence in general	Hospital	Qualitative	Brazil	Google Scholar	Article
Attitudes and knowledge of medical and nursing staff toward elder abuse⁽¹⁸⁾	2010	Violence in general	Hospital	Quantitative	Israel	Embase	Article
Elder Abuse. The nurse’s perspective ⁽¹⁹⁾	2005	Violence in general	Household	Qualitative	USA*	Embase	Article
Nurses’ encounters with older adults engaged in self-neglectful behaviors in the community: a qualitative study⁽²⁰⁾	2018	Self-neglect	Primary Care	Qualitative	Israel	Embase	Article
Factors related to Korean nurses’ Willingness to report suspected elder abuse⁽²¹⁾	2012	Violence in general	Hospital	Quantitative	South Korea	Embase	Article
Nurses’ clinical assessments of older clients who are suspected victims of abuse: an exploratory study in community care in Norway⁽²²⁾	2010	Violence in general	Household	Qualitative	Norway	North Grey Literature Collection (MedNar)	Article
Challenges in handling elder abuse in community care. An exploratory study among nurses and care coordinators in Norway and Australia⁽²³⁾	2011	Violence in general	Household	Qualitative	Norway and Australia	North Grey Literature Collection	Article
Identifying and handling abused older clients in community care: the perspectives of nurse managers⁽²⁴⁾	2011	Violence in general	Household	Qualitative	Norway	North Grey Literature Collection	Article
Critical care nurses’ perspectives on elder abuse⁽²⁵⁾	2012	Violence in general	Hospital	Qualitative	USA*	North Grey Literature Collection	Article
The relationship between nurses’ recognition regarding elder abuse and their attitudes and performance in dealing with elder abuse induced by Iranian family caregivers⁽²⁶⁾	2019	Violence in general	Hospital	Quantitative	Iran	Scopus	Article
Aspectos relacionados à violência contra o idoso: concepção do enfermeiro da estratégia saúde da família⁽²⁷⁾	2019	Violence in general	Primary Care	Qualitative	Brazil	LILACS	Article
Enfrentamento da violência intrafamiliar contra pessoas idosas pelos profissionais de saúde⁽²⁸⁾	2015	Intrafamily violence	Primary Care	Qualitative	Brazil	LILACS	Article
An international collaborative study comparing Swedish and Japanese nurses’ reactions to elder abuse⁽²⁹⁾	2012	Violence in general	Primary Care	Qualitative	Switzerland and Japan	PsycINFO	Article
Home care nurses’ experiences with and perceptions of elder self-neglect⁽³⁰⁾	2015	Self-neglect	Hospital	Qualitative	USA*	PubMed	Article
Elder abuse in Canada and Australia: implications for nurses⁽³¹⁾	1996	Violence in general	Various (unspecified)	Quantitative	Canada and Australia	Web of Science	Article

Measures of prevention of elder abuse	- Monitor the offender ^{(14) Australia.} - Try to hinder that the aged comet a crime against itself^{(20) Israel.} - Monitors the situation ^{(23) Norway and Australia.} - Supervises caregiver^{(23) Norway and Australia.} - Protects against undue influence^{(23) Norway and Australia.} - Home visits^{(24,29) Norway; Switzerland; Japan.} - Educates the elderly on the subject^{(26–28) Iran.}
Resources used to identify cases elder abuse	- Interviews^{(16,22,29,31) Brazil; Norway; Switzerland; Japan.} - Physical examination^{(16) Brazil.} - Abuse/neglect assessment form^{(19) USA.} - Clinical assessment^{(22,25) Norway, USA.} - Home visit^{(22) Norway.} - Tools (unspecified)^{(26) Iran.}
Interventions in situations of elder abuse	- Investigates the case^{(8,15,16,28,31) Ireland; Brazil; Canada and Australia.} - Welcomes older adults^{(14,17,23,26,29) Australia; Brazil; Norway; Australia; Will; Switzerland; Japan.} - Provides care^{(14,17,23) Australia; Brazil; Norway; Australia.} - Discusses the case with the team^{(15) Brazil.} - Discusses the case with social service^{(15) Brazil.} - Discuss the case with the elder health coordinator^{(15) Brazil.} - Conversation with family^{(16,23-24,29) Brazil, Norway; Australia; Switzerland; Japan.} - Record the case in the medical record^{(17) Brazil.} - Employs emotional and professional resources to solve the problem^{(20,30) Israel; USA.} - Carries out corrective actions^{(23) Norway; Australia.} - Counseling of abusers; victims’ counselling^{(31) Canada and Australia.} - Neutral attitude^{(18,26) Israel; Iran.}
Referral of cases of elder abuse	- Psychogeriatrics^{(8) Ireland.} - Leadership^{(8,24) Ireland; Norway.} - Another professional^{(16,24-25) Brazil, Norway, USA.} - Specialized Reference Center for Social Assistance (CREAS)^{(16) Brazil.} - Family Health Support Center (NASF)^{(16) Brazil.} - Social work^{(17,19,24–26) Brazil, USA, Norway, Iran.} - Psychology^{(17) Brazil.} - Adult Protection Service^{(19,23) USA, Norway; Australia.} - Elderly Assessment Team^{(23) Norway.} - Manager^{(25) USA.} - Competent bodies^{(28-29) Brazil; Switzerland; Japan.} - Hospitals^{(29) Switzerland, Japan.}
Denunciation and notification of cases of elder abuse	- To the competent bodies^{(15,19) Brazil, USA.} - To the Elder Council, Human Rights Office^{(17) Brazil.} - Reporting in the Reporting Diseases Information System (SINAN)^{(17) Brazil.} - Police^{(17,23-24,26-27) Brazil; Norway; Australia; Norway; Iran.}

Organizational problems	- Do not have strong legislation⁽⁸⁾ - Lack of organizational support⁽¹⁴⁾ - Lack of professional cooperation and responsibility⁽¹⁵⁾ - No guideline⁽²⁴⁾ - Fragility of the integration of public services aimed at elder abuse⁽²⁷⁾ - Shortage of mental health services⁽³⁰⁾ - Barriers of laws and policies⁽³⁰⁾ - Inability of the Adult Protection Service⁽³⁰⁾ -Dilemmas inherent to practice⁽¹⁴⁾
Professional training	- Lack of clear guidance⁽⁸⁾ - Lack of specialized preparation^(8,15,26-27) - Not knowing how to conduct^(15,19,23) - Difficulty with notification procedures⁽¹⁶⁾ - Difficulty in detecting and intervening^(16,18,24) - Ignorance of laws⁽¹⁸⁾ - Lack of evidence⁽¹⁹⁾
Personal issues	- Intimidations/threats/reprisals^(14,28) - Intrinsic factors for older adults^{(17,22,25,28)} - Do not want to get involved^(18,21) - Insecurity^(18,21) - The impact of personal values and experience^(20,25) - Resistance of the subjects involved⁽²⁸⁾ - Fear of exposing themselves⁽²⁸⁾