CHALLENGES FACED BY NURSES IN CARING FOR ELDERLY VICTIMS OF DOMESTIC VIOLENCE: A QUALITATIVE APPROACH

ABSTRACT

Objective:

To describe the challenges faced by nurses in detecting and caring for elderly victims of domestic violence.

Method:

an exploratory, qualitative study carried out with 13 nurses from 13 Family Health Strategy Units in Boa Vista, Roraima, Brazil, with interviews conducted between March and July 2021, which were subjected to Bardin’s content analysis.

Results:

Of those interviewed, 75% found no difficulties in detecting elderly people who had been abused. The interviewees refer the elderly to the Social Assistance Reference Center or to the competent bodies. Financial violence is prevalent.

Conclusion:

Detecting elderly people who have been abused depends not only on the professional, but also on the contribution of the victims, the community and the competent bodies. It was found that the participants did not have a formalized protocol for violence against the elderly, but only reported it and referred them to the relevant services.

DESCRIPTORS:
Nursing; Elder Abuse; Domestic Violence; Nursing Care; Primary Health Care.

RESUMO

Objetivo:

descrever os desafios enfrentados por enfermeiros na detecção e atendimento à pessoa idosa vítima de violência doméstica.

Método:

estudo exploratório, qualitativo, realizado com 13 enfermeiros de 13 Unidades da Estratégia Saúde da Família de Boa Vista, Roraima, Brasil, com entrevista realizada entre março e julho de 2021, submetida à análise de conteúdo de Bardin.

Resultados:

dos entrevistados, 75% não encontraram dificuldades na detecção de idosos violentados. Os entrevistados encaminham os idosos ao Centro de Referência de Assistência Social ou aos órgãos competentes. A violência financeira é prevalente.

Conclusão:

a detecção do idoso violentado não depende somente do profissional, mas da contribuição das vítimas, da comunidade e dos órgãos competentes. Verificou-se que os participantes não possuíam um protocolo formalizado de violência contra a pessoa idosa, realizando apenas notificação e encaminhamento aos serviços competentes.

DESCRITORES:
Enfermagem; Abuso de Idosos; Violência doméstica; Cuidados de Enfermagem; Atenção Primária.

RESUMEN

Objetivo:

Describir los retos a los que se enfrentan los enfermeros a la hora de detectar y atender a los ancianos víctimas de violencia doméstica.

Método:

estudio exploratorio, cualitativo, realizado con 13 enfermeros de 13 Unidades de Estrategia de Salud de la Familia de Boa Vista, Roraima, Brasil, con entrevistas realizadas entre marzo y julio de 2021, sometidas al análisis de contenido de Bardin.

Resultados:

de los entrevistados, el 75% no encuentra dificultades para detectar a las personas mayores víctimas de malos tratos. Los entrevistados remiten a los ancianos al Centro de Referencia de Asistencia Social o a los organismos competentes. La violencia financiera es frecuente.

Conclusión:

La detección de ancianos maltratados depende no sólo del profesional, sino también de la contribución de las víctimas, la comunidad y los organismos competentes. Se constató que los participantes no disponían de un protocolo formalizado para la violencia contra las personas mayores, sino que se limitaban a denunciarla y derivarlas a los servicios competentes.

DESCRIPTORES:
Enfermería; Abuso de Ancianos; Violencia doméstica; Atención de Enfermería; Atención Primaria de Salud.

HIGHLIGHTS

1. Nurses working in the Family Health Strategy need training and updates.

2. When cases are notified to the responsible bodies, they are often abandoned.

3. It is important to discuss the case with the Family Health Strategy team.

HIGHLIGHTS

1. Nurses working in the Family Health Strategy need training and updates.

2. When cases are notified to the responsible bodies, they are often abandoned.

3. It is important to discuss the case with the Family Health Strategy team.

INTRODUCTION

Population aging is set to increase in Brazil over the coming decades. According to a projection by the Brazilian Institute of Geography and Statistics (IBGE, in Portuguese), it is believed that by 2043 a quarter of the population (25.1%) will be aged 60 or over¹. According to IBGE estimates for 2019, the population of the state of Roraima reached 576,568 inhabitants, of which 38,591 were elderly. It is worth noting that Boa Vista is the municipality in Roraima where more than 60% of the state’s elderly population is concentrated1. In addition, the demographic projections of the Department of Informatics of the Unified Health System (DATASUS) reported that the number of elderly people has only been increasing in the municipality, since in 2010, the elderly represented 5.1% of the population of Boa Vista, and in 2018, 6.6%².

The greater longevity and increase in the number of elderly people has an impact on their care, as they can become victims of mistreatment and suffer all kinds of violations of their fundamental rights³. The Family Health Team (FHT), especially nurses, through home visits, is in the ideal scenario for building strategies and following up policies aimed at promoting healthy aging and guaranteeing human rights, since the senility of the population makes problems that were previously considered “silent” more visible, such as the phenomenon of violence against the elderly⁴.

Violence against the elderly is defined as any single or repeated act or lack of act, whether deliberate or thoughtless, which causes harm, unnecessary suffering and a reduction in the quality of life of the elderly person. It can be committed inside or outside the home, by a family member or by people who exercise a relationship of power over the elderly person, such as caregivers⁶.

As the victims are usually in a vulnerable situation, this type of violence is associated with power relations, causing adversity in the social, psychological and economic spheres. Therefore, this issue deserves special treatment, as well as the development of mechanisms to mitigate it⁵.

In this context, it is important to note the importance of Primary Health Care, especially the Family Health Strategy (FHS), as it plays an important role in recognizing violence against the elderly, by bringing health professionals closer to their clients’ homes. In addition, the FHT has an ethical and legal responsibility to identify and report suspicions of mistreatment of the elderly to the competent authorities, which facilitates investigation and action by protection services⁶. Articles 19 and 57 of Law 10.741/03 clearly mention the responsibility of health professionals and institutions to report cases of abuse of which they become aware. In the case of the elderly, the complaint must be registered with the Council for the Elderly (municipal, state or federal)⁷, the Public Prosecutor’s Office and police stations.

Para guiar este estudo, foi elaborada a seguinte questão norteadora: o enfermeiro da ESF encontra dificuldades na detecção e atendimento à pessoa idosa vítima de violência doméstica? Com base no exposto, esta pesquisa tem como objetivo descrever os desafios enfrentados por enfermeiros na detecção e atendimento à pessoa idosa vítima de violência doméstica.

To guide this study, the following guiding question was drawn up: Do FHS nurses encounter difficulties in detecting and caring for elderly victims of domestic violence? Based on the above, this study aims to describe the challenges faced by nurses in detecting and caring for elderly victims of domestic violence.

METHOD

This is an exploratory study with a qualitative approach, carried out through field research in 13 Basic Health Units in the municipality of Boa Vista, Roraima, Brazil. Exploratory research aims to provide greater familiarity with the problem, with a view to making it more explicit or forming hypotheses8. The municipality of Boa Vista currently has 34 Basic Health Units, 56 FHTs and six Family Health Support Center (NASF, in Portuguese) teams9. The 13 Basic Health Units were chosen in a non-probabilistic, non-random way, for convenience of access, without ESF nurses who met the research criteria.

The study population included FHS nurses from the municipality of Boa Vista. Of the 61 nurses belonging to the FHS, 13 took part in the interview, provided that they had been working in the ESF for at least six months and were carrying out home visits. The period of the COVID-19 pandemic made some health units unavailable, as they were left exclusively to treat symptomatic patients. It also hindered the participation of some nurses who, due to fear or time, chose not to take part in the research, and others did not meet the inclusion criteria.

The interviews were carried out until saturation was identified in the answers transcribed in the chosen program: WPS Office (Writer, Presentation, and Spreadsheets). The transcription of the answers was not shared with the study participants, since the recording was clear and did not generate any doubts in the researchers.

Data collection took place between March and July 2021. The tool used was a semi-structured interview, with seven open questions and a pre-applied script. The interview was conducted by one of the authors, a previously trained nursing graduate, in a room reserved at each participant’s health unit, lasting an average of 30 minutes. All the interviews were recorded on a smartphone, with the participant’s consent. After approval from the Research Ethics Committee, the researcher identified herself personally, presented the project and invited the nursing professional to take part in the research. The researcher responsible for the interviews was not a friend or acquaintance of the interviewees.

To guide the interview, a guiding question was drawn up: Do FHS nurses encounter difficulties in detecting and caring for elderly victims of domestic violence? The other questions were: what do you consider to be a case of violence against the elderly? Do you consider yourself a professional qualified to detect elderly victims of domestic violence? Do you find it difficult to detect violence against the elderly? If so, which ones? Do you follow any care protocols when you come across a case of violence against the elderly during a home visit? What strategy(ies) do you use to deal with violence against the elderly? Do you encounter any difficulties in assisting elderly victims of domestic violence during home visits? If so, which ones? What are the main indicators (signs) of violence that you analyze during the home visit to the elderly person?

The data was submitted to Bardin’s content analysis, which was carried out in three stages: pre-analysis; exploration of the material; and treatment of the results - inference and interpretation10. The data collected was then entered into the WPS Office program for textual analysis. Two of the authors worked on the content analysis after transcription, coding the data and observing the repetition of words and subjects in the answers.

The project was submitted to the Research Ethics Committee of the State University of Roraima, under Opinion No. 4.534.096, and forwarded to the National Research Ethics Commission (CONEP, in Portuguese). It should be noted that the request for consent to carry out this research was accepted by the Health Department of the Municipality of Boa Vista, Roraima. To protect the identity of those surveyed, the nurses were listed and identified by the term interviewee.

RESULTS

Thirteen ESF nurses took part in the study, 10 (77%) of whom were female and three (23%) male. The eight (61.5%) interviewees were aged between 30 and 39 at the time of the interview, while three (23.1%) were aged between 40 and 49, one (7.7%) was aged between 50 and 59, and one (7.7%) was aged between 60 and 69.

Based on the content analysis (Bardin) of the interviews, the following categories were constructed: Challenges and difficulties used by nurses in detecting elderly victims of domestic violence; Protocol for caring for elderly victims of domestic violence from the perspective of ESF nurses; and Main indicators of violence analyzed by nurses during home visits.

Detecting cases of violence against the elderly is not considered a difficulty from a professional perspective for nine of the participants, since home visits by nurses and Community Health Agents (CHAs) facilitate early detection and investigation of suspected cases.

Yes, there are patients that we feel a certain fear about, but it’s not difficult to detect because the health unit monitors them. We have the CHAs, who are fundamental to us, they help us a lot with our work on the streets. So, it’s easier to detect with their help because they’re more present [...]. (Nur.6)

[...] we have to have a holistic view, be on a day when you look at everything around you, the house, the appearance, the person who looks after this elderly person, how this person looks after this elderly person and how they refer to them [...] you just need to have a little bit of sensitivity to really get to know the environment you’re going to because it’s impossible the first time. (Nur.1)

No, at least I know it, I’ve been working in strategy for 20 years. So, you arrive in the environment where the elderly person is sleeping, the conditions they’re in, the way people address them and even the place they eat, everything is an indication that there’s some kind of violence there, some kind of aggression, if there is anything. (Nur.8)

Although nine of the participants reported having no difficulties in detecting elderly victims of domestic violence, they also highlighted some challenges to be overcome. Insufficient time for visits, the lack of information and resolution of cases by the competent bodies, the lack of family support, the lack of coexistence and protection that the elderly person has with their family are all reasons that hinder the process of detecting violence.

When it comes to information, we sometimes take it from the elderly because there are two sides. Sometimes, there are elderly people who are trying to protect their own family members. Sometimes they’re lonely; sometimes they miss this or that. When we go to visit, it turns out that he (the elderly person) himself says no, that everything is fine, and that it’s not true, trying to protect the situation from which he’s suffering. (Nur.2)

The difficulty with violence is that we don’t live with the elderly person; often we’re there, but only for a visit, and often they have a relative nearby, and they’re unlikely to talk. The cases we’ve found out about have been detected by a neighbor or someone who tipped us off. (Nur. 4)

Yes, because when the family realizes that we’re asking too many questions, they make sure that we can no longer access the elderly person. What I find most difficult to detect and make happen is the elderly person themselves, because they try to protect the family, and want to justify something [...]. (Nur.10)

Regarding care, three of the nurses said that they encountered difficulties when caring for elderly victims of domestic violence. These difficulties involve issues related to the absence of the family in the home, elderly people with no discernment, covered areas that are dangerous, the family’s lack of receptiveness to the health team during the home visit and the victim’s fear of the consequences of reporting the incident.

That part of Cauamé is a bit dangerous, there are drug dealers, inmates, ex-convicts, we’ve had people escape. So this also means that you can’t invade too much because we don’t know what we can get away with, so I think that’s the biggest difficulty. (Nur.3)

No, but we do have difficulties, for example, there are elderly people we go to and the caregiver isn’t there, and we can’t get into the home. (Nur.4)

No, the difficulty is when they’re older and have already been diagnosed with other illnesses, and sometimes they end up telling the truth, in the middle of .... not saying anything, you know? So, you can’t absorb what’s really true and what isn’t. (Nur.5)

The interviewees emphasize the importance of home visits in detecting domestic violence because they can be used to carry out a nursing consultation, which allows them to get to know and assess the patient, as well as observe the environment in which they live. They also report that the CHA are the main people involved in detecting suspected cases because their visits are more frequent than those of the nurses, who usually visit on a specific day.

Most of the time, it’s a home visit by the CHA. They’re the ones who have the most contact with these patients, or at the doctor’s appointment, when you’re going to do a physical examination, that’s why the home visit is important. The CHA are more present than us nurses, we have a date to visit [...]. (Nur.3)

[...] we have the visits... you go to the nurse’s appointment, which our CHA... “oh, nurse, I’ve noticed that something has happened to the patient, Mr. Francisco”, so I go there. We’re not going to scare the family, we’re going to check on the patient, talk to them, ask them questions, and then we will take all the steps we can to help the patient [...]. (Nur.6)

The protocol used by most of the professionals interviewed is to fill out the violence notification form, then document the case in a report and, finally, refer it to the Social Assistance Reference Center (CRAS). Another course of action was to call in the competent bodies to resolve the situation.

Yes, you detect it, then you have a notification form that you fill in, but it’s a general violence form, it’s not aimed at the elderly, no, then you fill it in and notify the doctor, if you need any kind of care; you notify CRAS, if they need support [...]. (Nur.7)

Yes, you must report the violence. We make a report and send it to CRAS and CREAS so that they are aware of it. (Nur.11)

Three nurses reported not having or not knowing a protocol for these cases.

That I know of? No. (Nur.1)

It’s... not a protocol, as I don’t think there is one. We follow the normal consultation, but there are notifications... no protocol, it’s internal, for example, if I detect it, I’m going to approach it in such a way that the family doesn’t run away from me [...]. (Nur.5)

No, we don’t have protocols like that, it’s support. Sometimes, we call in the psychologist, we don’t have a social worker, we go and ask the doctor for help so that we don’t have to rely solely on our vision, and I think that’s very bad. (Nur.10)

Within this category, the nurses reported on the different types of violence, as well as some indicators of violence that they analyze during the visit. The nurses identify physical violence using the following indicators: unexplained injuries; inadequate care or poor hygiene standards; and malnutrition without a disease-related cause.

[...] physical violence, notice it because every time, the elderly person has some kind of bruise, hematoma, scar, wound, cut or injury. You have to pay attention [...].” (Nur.1)

[...] “What was that? Why is it purple?”, “Why is it bruised here?”. We ask questions, we talk so that we know if it’s physical violence or if it’s just a bruise [...]. (Nur.3)

Often, the lack of hygiene, sometimes thinness, being poorly dressed. We can already see that the elderly person is not being well looked after. (Nur.9)

Financial violence presents itself through financial indicators, such as atypical withdrawals of money from the elderly person, lack of comfort when they could afford it, changes to wills or property titles for family members.

Sometimes the person has a certain pension, a possession, a house, for example, and we notice that there is intrigue between the children themselves because of the inheritance [...]. (Nur.2)

[...] what we see most is financial violence. Generally, his card doesn’t stay in his possession, someone else takes care of it, the family lives off that money, and sometimes he doesn’t have the autonomy to say “no, I need to buy this with my own money because I don’t have it”; they know they have to support the family, and we see this a lot more here. (Nur.10)

Psychological abuse is identified through behavioral and emotional indicators, such as fear, sadness, avoidance of physical, eye or verbal contact with the person caring for the elderly.

[...] if it’s psychological/emotional violence, it’s seeing the person sad and crying. (Nur. 1)

[...] as I’ve already told you, but often the elderly person doesn’t want to talk, they’re afraid. When we realize that this elderly person is afraid, I think it’s an indicator of violence because they won’t be afraid if nothing is happening, they won’t be afraid to talk, to tell us what’s going on, that’s already an indicator. (Nur. 4)

[...] someone from the family or someone else arrives, and then they become tearful, they don’t face the person, they don’t want to talk to the person, they’re afraid, you realize that the elderly, at a certain age, become like a child. (Nur.7)

DISCUSSION

Based on the analysis of the interviews, it was found that for the interviewees, home visits are a facilitating tool in the process of detecting violence against the elderly, and are considered one of the main strategies within the FHS, with the CHA being cited as the main characters, since violence is, in most cases, recognized through them.

In Primary Care, the possibility of detecting the existence of violence is reinforced by home visits, a practice which allows professionals to analyze the environment and reality of the user’s home¹¹. A study on how nurses act in the face of domestic violence suffered by the elderly indicates that, for professionals, going to their clients’ homes is the main way of finding out about mistreatment practiced against an elderly person¹².

As well as revealing elderly people who have been physically abused, visits make it possible to recognize another type of violence: neglect. Article 4 of the Statute of the Elderly states that no elderly person shall be subjected to any form of neglect, discrimination, violence, cruelty or oppression, and any violation of their rights, whether by action or omission, shall be punishable by law. Abandonment is a form of violence that manifests itself in the disappearance of support or assistance from those responsible for fulfilling their duties to care for an elderly person. That’s why it’s so important for nurses and CHA to carry out visits, considering the preparation, critical eye and help they offer, which can help detect and deal with such situations.

Home visits are also among the main strategies cited by the interviewees. In a similar study¹³, 42% of FHC professionals mentioned home visits as an important strategy for detecting violence against the elderly. Although this is the team’s working tool, it is the CHA who visit more often and, for this reason, they are the key element in detecting cases of violence against the elderly in the home, due to their proximity to the reality of the residents of the area¹¹.

Regarding the challenges faced in detecting violence against the elderly, the survey showed how unprepared nurses are to approach an elderly victim of domestic violence, which can lead to an increase in cases of silent aggression, as well as late interventions.

When faced with a suspicion of violence, health professionals need to ensure the right conditions for the victim to be able to: discuss the situation they have experienced with due confidentiality; show sensitivity and respect; ask necessary questions without judgment; adopt positive and protective attitudes; encourage them to make their own decisions; and act together with the team. These are actions that facilitate the initial management of cases that are detected¹⁴.

Insufficient time to carry out visits is one of the difficulties cited by nurses, due to work overload and the high demand for care at the health unit. A study carried out in São Paulo, regarding the frequency of home visits by FHS professionals, indicated that 22% of those interviewed do not carry out visits and 38% say that they only do so when requested¹⁵. This indicates that nurses are gradually losing ground in home care, which is one of their activities that allows them to take a professional look at the process of detecting cases of violence in the home.

Another difficulty identified by the participants was the protection that the elderly have with the family that violates them. Elderly people prefer to suffer in silence rather than have their family life disrupted, as they fear loneliness and contempt more than the abuse they suffer¹⁶.

Due to the involvement of a family structure and the lack of support from the victim, interventions in these situations become complex, with omission being the only choice for nurses who are unprepared to handle these cases¹¹. Encouraging the elderly population and society in general to report cases of abuse to the relevant authorities, as well as providing support and protection for victims, is a course of action that would help to reduce cases of violence and punish aggressors¹¹.

The lack of resolution of cases by the competent bodies and the absence of information and family support are also stumbling blocks for nurses seeking to resolve cases of violence committed in the micro-area in which they are responsible. This information corroborates the study “Intrafamily violence and the strategies for action by the Family Health team”, carried out in 2014, which highlights the lack of support and resolution by the competent bodies as difficulties in developing strategies to deal with intrafamily violence¹⁷.

Knowledge of the protocol for treating victims of violence is essential for handling cases. Although the majority of participants report following a protocol for care, it is clear that it is not formal and recommended, since the participants’ reports only inform about notification and referral to the competent services.

Conduct and actions are needed that include a differentiated approach to the victim, providing an opportunity to listen transparently and showing trust, as well as nursing care based on physical and psychological assessment; discussion of the case with the FHT regarding the fate of the occurrences; notification and referral to the responsible body¹⁴,¹⁸.

The testimonies show that once the cases have been notified and sent to the responsible bodies, they are forgotten and abandoned. This is due to the lack of feedback from the service to which they were referred, hindering the continuous care of these users in Primary Care¹⁷, ¹⁹-²⁰.

Regarding the indicators of violence analyzed during home visits, the main ones described by professionals are physical violence, although they do mention the financial violence that the elderly are commonly affected by, which would be included in the indicator of property violence, as well as psychological violence. According to the 2016 Cultural Map of Violation of the Rights of the Elderly in the municipality of Boa Vista, financial, psychological and physical violence are the most prominent, among which financial violence is the most violated and the most common²¹.

For professionals, physical violence is easy to detect because it is perceptible. However, when they refer to forms of oppression that doesn’t leave physical marks, such as financial violence, which had indicators cited by less than half of the participants, its complexity increases even more. Considering that, to identify such violence, it is necessary to get closer to the victim in such a way as to establish a communication that makes it possible to understand the real situation, home visits are essential.

The study had some limitations, such as the insufficient sample size to obtain more accurate results, due to the unavailability of professionals to take part in the study, and the COVID-19 pandemic, which made it difficult to access some primary care units. It is possible that future research will include elderly people in the sample so that the results can be analyzed from different perspectives, that of the professional and the victim of aggression.

FINAL CONSIDERATIONS

This study made it possible to understand that nurses working in the FHS need training and updates to detect and care for elderly victims of domestic violence.

It was found that the professionals interviewed felt prepared to detect violence against the elderly, although there were some challenges. Insufficient time for visits, the lack of information and resolution of cases by the competent bodies, the lack of family support, the lack of coexistence and protection that the elderly person has with their family are all reasons that hinder the process of detecting violence against the elderly.

It was also found that detection depends not only on the ability and aptitude of the professional to identify such aggression, but also on the contribution of the victims involved and the community.

It was found that most of the participants followed a non-formalized protocol for violence against the elderly, which only had the objective of notifying and referring to the competent services, and did not include the care or assessment of the violated individual.

The indicators serve to help to guide professionals in identifying the possibility of elder abuse. Unexplained injuries, poor hygiene standards, atypical withdrawals of money from the victim, change of will, fear and sadness were indicators commonly mentioned by the professionals, although most of them, when asked, referred to the different types of violence, and there was a noticeable lack of knowledge about the indicators.

REFERÊNCIAS

• ⁰¹
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Edited by

Associate editor: Dra. Susanne Betiolli

Publication Dates

• Publication in this collection
  27 Nov 2023
• Date of issue
  2023

History

• Received
  08 June 2022
• Accepted
  19 July 2023