Nurses and care delivery to elderly women: a social phenomenological approach

Abstracts

OBJETIVO: compreender a ação de cuidar da mulher idosa, sob a perspectiva do enfermeiro. MÉTODO: estudo fenomenológico, com dez enfermeiros que atuam em Unidades de Atenção Primária à Saúde, entrevistados entre setembro de 2010 e janeiro de 2011. RESULTADOS: o enfermeiro considera, para a realização do cuidado, a bagagem de conhecimentos e a situação biográfica da mulher idosa e valoriza a participação da família como mediadora do cuidado. Esse profissional possui acuidade para captar as demandas específicas da idosa, contudo, depara-se com dificuldades para cuidar dessa clientela. Espera realizar um cuidado qualificado para essas mulheres. CONCLUSÃO: a abordagem teórico-metodológica da fenomenologia social permitiu develar que o enfermeiro projeta o cuidado qualificado à mulher idosa como uma possibilidade no contexto em que está inserto. Tal perspectiva de cuidado inclui a participação de diversos atores sociais e setores da saúde, pressupondo investimento coletivo em estratégias de ação e formação profissional, consoantes às particularidades e necessidades de cuidado da mulher idosa, identificadas pelo enfermeiro.

Enfermagem; Saúde do Idoso; Cuidados de Enfermagem; Assistência Integral à Saúde; Pesquisa Qualitativa

OBJETIVO: Comprender la acción de cuidar a la mujer adulta mayor, a partir de la perspectiva del enfermero. MÉTODO: En este estudio fenomenológico se entrevistaron, entre septiembre del 2010 y enero del 2011, diez enfermeros que trabajaban en Centros de Salud. RESULTADOS: Para la realización del cuidado, el enfermero considera el bagaje de conocimientos y la situación biográfica de la mujer adulta mayor, así como, valoriza la participación de la familia como mediadora del cuidado. Ese profesional posee acuidad para captar las demandas específicas de la mujer adulta mayor, sin embargo se depara con dificultades para cuidar a esa clientela. El enfermero tiene la expectativa de realizar un cuidado calificado para esas mujeres. CONCLUSIÓN: El abordaje teórico-metodológico de la fenomenología social permitió develar que el enfermero se proyecta para ofrecer un cuidado calificado para la mujer adulta mayor, considerando las posibilidades en el contexto en el que está inserto. Eso incluye la participación de diversos actores sociales y sectores de salud, reconociendo un esfuerzo colectivo en estrategias de acción y formación profesional consonantes con las particularidades y necesidades del cuidado para la mujer adulta mayor identificadas por el enfermero.

Enfermería; Salud del Anciano; Atención de Enfermería; Atención Integral de Salud; Investigación Cualitativa

ORIGINAL ARTICLE

Nurses and care delivery to elderly women: a social phenomenological approach

Sebastião Caldeira^I; Miriam Aparecida Barbosa Merighi^II; Luz Angelica Muñoz^III; Maria Cristina Pinto de Jesus^IV; Selisvane Ribeiro da Fonseca Domingos^V; Deíse Moura de Oliveira^VI

^IPhD, Professor, Centro de Ciências Biológicas e da Saúde, Universidade Estadual do Oeste do Paraná, Brazil

^IIPhD, Full Professor, Escola de Enfermagem, Universidade de São Paulo, Brazil

^IIIPhD, Full Professor, Universidad Andrés Bello, Chile

^IVPhD, Associate Professor, Faculdade de Enfermagem, Universidade Federal de Juiz de Fora, Brazil

^VPost-doctoral fellow, Escola de Enfermagem, Universidade de São Paulo, Brazil

^VIDoctoral Student, Escola de Enfermagem, Universidade de São Paulo, Brazil

^{Corresponding Author}

ABSTRACT

OBJECTIVE: To understand how nurses see care delivery to elderly women.

METHODS: In this phenomenological study, ten nurses working at Primary Health Care Units were interviewed between September 2010 and January 2011.

RESULTS: In care delivery, nurses consider the elderly women's knowledge background and biographical situation, and also value the family's participation as a care mediator. These professionals have the acuity to capture these women's specific demands, but face difficulties to deliver care to these clients. Nurses expect to deliver qualified care to these women.

CONCLUSION: The theoretical and methodological approach of social phenomenology permitted revealing that the nurse designs qualified care to elderly women, considering the possibilities in the context. This includes the participation of different social actors and health sectors, assuming collective efforts in action strategies and professional training, in line with the particularities and care needs of elderly women nurses identify.

Descriptors: Nursing; Health of the Elderly; Nursing Care; Comprehensive Health Care; Qualitative Research.

Introduction

Increased life expectancy imprints new traits on the world population. This fact entails a global modification of the demographic pyramid, with an expressive growth of the elderly population. Concerning Brazil, the World Health Organization estimates that, by 2025, the country will rank sixth in number of elderly people, reaching 30 million. Between 1980 and 2000, the population aged 60 years or older experienced an important increase, from 7.3 million to 14.5 million, accompanied by a parallel rise in the country's mean life expectancy⁽¹⁾.

With regard to the female population, statistics show that there are more women than men. In the most recent census, which the Brazilian Institute of Geography and Statistics developed in 2010, 8,549,259 males and 10,732,790 females were counted. This finding also comes with a higher life expectancy of 77.01 years for women, against an estimated 69.4 years for the male population⁽²⁾.

The Brazilian panorama is observed around the globe: women live longer than men all over the world, use the health system more and need greater care due to the problems associated with biological, social and economic factors⁽³⁾. Hence, this fact indicates a superposition of the global female elderly population, entailing specific health demands in this new reality.

These demands are related to particularities inherent in the population aging process, which come with important consequences for elderly health. Thus, a greater disease burden is highlighted in this population, including more disabilities and greater use of health services⁽⁴⁾. The social and demographic changes evidenced today produce new care needs in this population.

In that context, the primordial role of nurses stands out, whether in direct care delivery to elderly patients or in training for caregivers and/ore family members⁽⁵⁾.

With respect to nursing care for elderly women, it is known that these professionals are closely linked with their care, whether direct and/or indirectly. Therefore, nurses need to be prepared to take care of these people, with a view to attending to their health needs⁽⁶⁾.

In view of the considerable number of elderly people – particularly women – and the importance of knowing how nurses deliver care to them, the following questions guided this research: How do nurses take care of elderly women? How do nurses perceive these women's care needs? What do nurses expect in care delivery to elderly women?

The aim in this study is to understand care delivery to elderly women from a nursing perspective. This kind of studies offer important contributions to Nursing by providing elements that permit reflections on these professionals' practice involving elderly women, in view of their needs and moment in the lifecycle.

Current Brazilian and international studies published in this journal about the theme present scientific evidence from an elderly perspective – with emphasis on quality of life-related aspects^(7-8) and this group's functional ability^(9-10). Therefore, the nursing perspective on care delivery to elderly women represents an important contribution to the knowledge constructed about the theme in this journal.

Moreover, the research arouses reflections that go beyond this dimension, granting visibility to health service management and professional Nursing education institutions concerning elderly care. Thus, a parallel can be drawn between the care accomplished and what those involved in – direct or indirect – care to these clients intend to achieve.

Theoretical framework

Qualitative study based on Alfred Schütz' Social Phenomenology, with the aim of understanding care delivery to elderly women from a nursing perspective. Therefore, the following concepts were used: life world, intersubjectivity, knowledge collection, biographic situation, reciprocity of perspective, social action and typification⁽¹¹⁾.

The life world is the human interaction scenario in which the person uses the knowledge collection deriving from his/her experiences, which are transmitted to past and future peers in order to signify their experiences⁽¹¹⁾. This interpretation is reached according to the cultural and ideological position – called biographic situation – that allows subjects to reflect on and understand their actions and relation with the world⁽¹¹⁾. In this context, intersubjectivity is a premise of social life and experience is the source of human meanings. The latter are not individual as, to the extent that they are contextualized in the intersubjective relation, they constitute a social meaning⁽¹¹⁾.

In face-to-face situations, this relation is permeated by common interests learned among subjects, which is called reciprocity of intention⁽¹¹⁾. This takes the form of typical constructions of thought objects that reveal the apprehension of these objects and of their aspects the subjects are familiar with, which are related in the social world⁽¹¹⁾.

The subject acts in this world through existential reasons. The "reason for" is the orientation to the future action (anticipated, imagined act, subjective meaning of the action). The "reason why" is related to past and present experiences (explanation after the event). It is oriented at available knowledge and represents an objective category the researcher has access to⁽¹¹⁾.

When considering several perspectives originating in different biographical situations, real or potentially common objects are chosen and interpreted identically. Thus, meanings are objectified through a conceptual scheme that permits grouping common-sense information – typification – which furthers the understanding of man in his social relations⁽¹¹⁾.

Method

The conceptual premises presented earlier served as the guiding axis for this study, which involved ten nurses working at Primary Health Care Units in a city in Western Paraná. Their statements were obtained between September 2010 and January 2011.

The nurses were predominantly female, between 23 and 47 years of age, and without a specialization degree in elderly health. Nurses were included if they were directly active in care delivery to these women, and excluded if they did not comply with this criterion.

Declarations were obtained through an open interview, which was recorded after the participants' Informed Consent had been obtained in writing, using the following questions: How do you perceive the health care needs of an elderly woman? How do you take care of this woman? What do you expect when you take care of an elderly woman?

The nurses were identified by the letter E, followed by a number from 1 to 10. The number of subjects was not determined a priori. Instead, interviews were closed off when the significant contents deriving from the statements were repeated and when the proposed aim was reached.

The organization and general analysis of the declarations were based on the theoretical and methodological premises of Social Phenomenology research⁽¹²⁾: a) careful reading of each statement to capture the global meaning of the subjects' experience; b) grouping of significant aspects present in the declarations to compose the categories; c) analysis of the categories, seeking to understand the "reasons for" and the "reasons why" of the participants' actions and, e) discussion of the results in the light of Alfred Schütz' Social Phenomenology and other reference frameworks related to the theme.

The project received approval from the Ethics Committee for Research involving Human Beings at Universidade Estadual do Oeste de Paraná, registered under number 357/2010.

Results

When referring to how they take care of elderly women, their care needs and what they expect in care delivery to these clients, the nurses permitted the identification of a context of meanings inscribed in the care action that was expressed through the categories: "Particularities in care" and "Family participation", which express the "reasons why", and by the category "Qualified care", which expresses the "reasons for".

Particularities in care (reasons why)

In care delivery, the nurses consider the elderly women's life context, knowledge and experiences. They indicate that they use this information in the planning and implementation of care activities for these clients: [...] they have a lot of experiences, good and bad, and we nurses need to use this to plan and perform care [...] (E8).

In that sense, the nurses perceive that factors like education and social context can interfere in the health of elderly women, as well as the care they receive: [...] health depends on the social [...] education for example: How am I going to teach them? ... if they can't read and have difficulties to learn [...] (E3).

In addition to this context, limitations are evidenced that are typical of the aging process and hamper communication with the elderly women, underlining weakness and mobility, verbal communication and hearing losses: [...] it is very difficult to communicate with them [...]. They can't hear well, they are unable to understand what we say [...] (E4). [...] they have physical, hearing and sight problems that aggravate the situation even further (E10).

The particularities present in the aging phase make the nurses identify specific health needs in this type of patients. Among these, injury prevention is highlighted as something fundamental at this moment in the women's lives: [...] I believe we have to prevent in order to grant them a healthy old age. Deliver care that can reestablish their health and, at the same time, prevent other complications, other illnesses that will happen. So, I think the main thing is prevention (E9).

Among the activities developed with elderly women, group educational activities are identified as an important care strategy for these clients, which the nurses consider as a space for women's body communication and socialization: [...] in these group activities, I see that they feel better [...] in dancing for example, you can see the happiness in their faces. I see it because the body talks (E8).

Family participation (reasons why)

The family is considered a partner with a view to effective care delivery to these women. This co-participation is seen as positive, for the health team's work as well as to grant these women the physical and affective support they need in this phase of life: [...] the family has to participate together with the health unit team [...]. If the family does not get involved, I'm going to take care, orient, follow her here, but there won't be that continuity at home (E9).

When family members abandon an elderly woman, on the opposite, the nurses considered this an aggravating factor for care planning and continuity: [...] the family abandons her and doesn't come to the consult with her, I give her the orientation [...] and then she goes by totally lost, she's alone at her home [...] and it's very difficult like that (E1).

One theme the nurses highlight is these women's participation as caregivers in the family context, especially for children and grandchildren. That is appointed as an important counterpoint when thinking about care as, when they assume this role, these women break a very common cycle of solitude, in which they are distant from their relatives: [...] today, we see elderly women assuming daily activities. Besides taking care of the family, they also take care of the grandchildren (E8).

Qualified care (reasons for)

When they take care of elderly women, the nurses expect to deliver qualified care, considering both the way this care is delivered and conducted, as they intend to integrate people and services involved in care: [...] programs, intersectoriality and joint work need to get better. Qualification is needed, sensitization, discuss the problem, create strategies (E3).

When reflecting on how they take care, the nurses perceive that their education is insufficient for this type of care. They consider investments in their professional education a possible route towards care qualification: [...] there are still many flaws I see in education [...]. I hope there will be more training and qualification programs on elderly health [...] What is done here is based on our work experience (E1).

Concerning investments in elderly care, the nurses aspire to the definition and management of their activities in Primary Health Care involving this clientele: [...] we need something that guides us, like a protocol, to be able to give a solid response, so that women can follow this indication, because sometimes it's difficult [...] you say one thing and the other says something else and the elderly woman does not know who to listen to (E7).

Discussion

The reflections that emerge about nursing care delivery to elderly women take place in the life world, in the context of these professionals' experiences (reasons why). That permits unveiling that what is typical of care delivery is based on the particularities of this phase in these women's lives as well as on the life context they are inserted in.

Taking care of this group involves establishing a relation based on intersubjectivity, which permits accessing the reality a person experiences. In planning and performing care, the nurses take into account these women's knowledge background and biographic situation. This presupposed the valuation of biological, psychological and social aspects, in the framework of values, beliefs, culture and past experiences⁽¹³⁾.

As a limiting aspect of care, the nurses underline the weakness surrounding elderly women. This weakness is expressed by mobility, hearing and sight deficits, hampering effective communication in the intersubjective relation established in care. When considering these particularities, the nurses can prevent the development or worsening of this weakness, reducing institutionalization, hospitalization and mortality rates in this population⁽¹⁴⁾.

The nurses highlight the activities involved in health promotion and disease prevention for elderly women. Group educational work was referred to as a care strategy that enhances health promotion, positively affecting their quality of life.

As for the elderly women's participation in group activities, one study found that this contact entails great improvements and changes in health, self-esteem and valuation of life. Many of them reported that the activities performed in groups contributed to perform their daily activities, and also generated acknowledgement and valuation, by relatives as well as by society in general⁽¹⁵⁾.

Programs for the inclusion of elderly people share common goals, like reverting stereotypes and prejudices about old age, promoting self-esteem, rescuing the citizenship dimension of people in this phase of life, encouraging autonomy, independence, self-expression and social reintegration, in search of a successful old age. This is an alternative for the elderly's inclusion in social spaces, with a view to improving their quality of life and improving their citizenship⁽¹⁶⁾.

Another typical aspect in care delivery to this group from the nurses' viewpoint (reasons for) is based on the importance granted to the family as a key counterpart in care delivery. Positive relations in life with the family help elderly patients to remain active and autonomous, as evidenced not only in their role as receivers of help and care, but also in their feeling useful, especially when they can help other family members. The bond between these women and their family is important to construct a relation of trust, intimacy and to tighten affective bonds. This will allow the stakeholders (elderly woman and family) to adopt the same focus on health care, indicating reciprocity of perspectives in this relation.

Elderly people who are well integrated in their families and other social groups are better able to recover from illnesses and increase their survival, given that social isolation is an important risk factor for morbidity and mortality⁽¹⁷⁾.

In this study, in some situations, family abandonment was evidenced, enhancing elderly women's vulnerability. This vulnerability is based on the fact of feeling wanting, without affection or care from significant others. It is known that, nowadays, the elderly live without family support, with justifications based on the absence of conditions or desire to assume the care involved in the aging process⁽¹⁸⁾.

In Western countries, the family's involvement in elderly care happens differently. The children prepare their parents for self-care in old age⁽¹⁹⁾. In the Netherlands, families increasingly prepare their children for care delivery to elderly parents, making them value and seek their independence through self-care. It is highlighted, however, that self-care is not always possible, considering that the chronic illnesses affecting the elderly can cause psychophysical dependence and, in most cases, financial dependence⁽²⁰⁾.

On the other hand, nowadays, this group is assuming roles that historically have been indicated neither in the literature, nor in public policies. It is evidenced that these roles turn elderly people into participants in family care⁽²¹⁾. Mainly the maternal grandmother is considered an extension of the mother. A person whose wisdom and confidence allows her to take care of the people around her, representing a protective figure⁽²²⁾.

Considering the context of experiences in care delivery to elderly women, the nurses plan actions and restructure them based on different situations, which serves as the base for new care actions (reasons for). This motivation remits the subjects to actions that are imagined and originate in each subject's knowledge background and biographic situation⁽¹¹⁾.

The nurses expect care delivery to elderly women to result from the integration among the professionals involved, in line with service integration. They plan care directed at these women, using the instruments that are better able to systemize it. Concerning clinical protocol, Brazilian studies discuss Nursing Care Systemization as a scientific instrument used to support the nurses in care qualification. This is aimed at oriented care, involving care actions based on comprehensiveness, quality and organization⁽²³⁾.

Qualified care was a nursing action project for these clients, which should by guided by an integrated service, accompanied by investments in professional education (reasons for). The nurses disclose difficulties in care delivery to elderly women, resulting from the efficiency of their education process. This stands out as a complex, dynamic and changing theme, considering the elderly's needs as well as the professional requisites necessary to adequately respond to these needs⁽²⁴⁾.

Therefore, the curriculum of health education courses should be adequate to respond to this demand. In addition, partnership among managers, nurses and other stakeholders in elderly health promotion is seen as a means to broaden and qualify care actions for this population⁽²⁵⁾.

The set of categories that join the "reasons why" and the "reasons for" permitted the construction of typical nursing characteristics in care delivery to elderly women, as the professionals who take into account these women's knowledge background and biographic situation and value family participation as a care mediator. The nurses hope to deliver qualified care to these women, based on professional education that is compatible with this public's health needs.

Considering that care delivery to elderly women involves a range of knowledge and practices, understanding it from the perspective of a sole professional category limits the present study findings, as it translates the nurses' specific experiences and expectations, which can differ from other professionals.

The available evidence can offer possibilities for reflection and action in care, teaching and research on elderly health. This possibilities should be linked with perspectives of knowledge gaining in these areas, through the restructuring of nursing practices and professional education.

Conclusion

The understanding of care delivery to elderly women from a nursing perspective revealed that, guided by elderly women's knowledge background and biographic situation, identify particularities that imprint a different design on care.

The outlines of these particularities are based, among other things, on the weakness characteristic of aging, and on low socioeconomic and educational levels, as factors that hamper care delivery to this group.

The importance of the social support network was evidenced, particularly marked by the family's presence as a care mediator. Nurses should involve the family in care delivery to elderly women – ranging from planning to execution - so that all stakeholders (nurse, elderly woman and family) find a meaning in the care plan, with a view to furthering adherence.

The nurses consider the use of care protocols for these women as an instrument that mediates health care for these clients. It should be considered, however, that these instruments propose a partial and objective care approach. It is the nurse's responsibility to use them in a qualified manner. This presupposed theoretical-practical knowledge that permits recognizing the subjective aspects of elderly women's care needs.

It is important to highlight that, to respond to these needs, professionals are needed whose education supports them in care practice. In that sense, a considerable void is outlined, as the growing demand for elderly care does not come with professionals who are able to deliver qualified care in daily health service work.

These nurses' perspective on the care delivered to elderly women shows that these professionals have the acuity to capture the elderly women's specific demands, although they are confronted with difficulties to take care of these clients.

The theoretical-methodological approach of social phenomenology permitted revealing that nurses project qualified care delivery to elderly women as a possibility in the context they are inserted in. This care perspective includes the participation of different social actors and health sectors, presupposing collective efforts in action and professional education strategies, in line with the particularities and care needs the nurses identified for elderly women.

As the phenomenon is shown from one perspective, this study represents one facet of health care delivery to elderly women. Therefore, other perspectives should be investigated, with a view to elaborating on and deepening the aspects that emerged in this investigation.

Received: Mar. 30^th 2012

Accepted: Sept. 24^th 2012

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Publication Dates

• Publication in this collection
  20 Nov 2012
• Date of issue
  Oct 2012

History

• Received
  30 Mar 2012
• Accepted
  24 Sept 2012