MARKERS OF VIOLENCE AGAINST OLDER ADULTS FROM THE NURSES’ PERSPECTIVE^*

ABSTRACT

Objective:

to identify the markers of violence against older adults from the nurses’ perspective.

Method:

a qualitative study conducted between June and September 2021 in the state of Paraíba (Brazil), with the participation of nine nurses in two focus groups. The empirical material was transcribed in full and transformed into a text corpus with similarity analysis.

Results:

in the central core of the maximum tree, it was possible to observe terms common to more than one typification of violence, such as: “cycle of violence”, “trust”, “dominate”, “psychological distress”. In physical violence: “fractures”, “break” and “throw”; in psychological violence: “threat”, “fear”, “shame”, “injury”, “vaginal discharge” and “vaginal”; in financial violence: “withdrawal”, “dependence” and “take”; in neglect: “lack”, “supply” and “hygiene”; and in abandonment: “depression”, “loneliness” and “sadness”.

Conclusion:

his research values Nursing as a science and profession, especially in the forensic area, by investigating violence against older adults. The nurses’ perception makes the Nursing Process more reliable and useful in identifying, reporting and solving incidents.

KEYWORDS:
Older adults; Violence; Abuse against Older Adult; Forensic Nursing; Nursing Care

RESUMO

Objetivo:

identificar os marcadores de violência contra pessoa idosa na perspectiva de enfermeiros.

Método:

estudo qualitativo conduzido no estado da Paraíba - Brasil, com a participação de nove enfermeiros, em dois grupos focais, durante junho e setembro de 2021. O material empírico foi transcrito na íntegra, transformado em corpus textual com análise de similitude.

Resultados:

no núcleo central da árvore máxima foi possível observar termos comuns a mais de uma tipificação de violência: “ciclo de violência”, “confiança”, “dominar”, “sofrimento psíquico”. Na violência física, “fraturas”, “quebrar” e “jogar”; na psicológica, “ameaçar”, “medo”, “vergonha”, “lesão”, “corrimento vaginal” e “vaginal”; na financeira, “saque”, “dependência” e “pegar”; na negligência, “falta”, “insumo” e “higiene”; no abandono, “depressão”, “solidão” e “tristeza”.

Conclusão:

esta pesquisa valoriza a Enfermagem como ciência e profissão, especialmente na área forense, ao investigar a violência contra a pessoa idosa. A percepção do enfermeiro torna o processo de enfermagem mais confiável e útil na identificação, notificação e resolução das ocorrências.

DESCRITORES:
Idoso; Violência; Abuso de Idosos; Enfermagem Forense; Cuidados de Enfermagem

RESUMEN

Objective:

identificar marcadores de violencia contra las personas mayores desde la perspectiva de los enfermeros.

Método:

estudio cualitativo realizado en el estado de Paraíba, Brasil, con nueve enfermeros, por medio de dos grupos focales, durante junio y septiembre de 2021. El material empírico fue transcrito de forma completa, transformado en corpus textual y sometido a análisis de similitud.

Resultados:

en el núcleo central del árbol máximo fue posible observar términos comunes a más de un tipo de violencia: “ciclo de violencia”, “confianza”, “dominar”, “sufrimiento psíquico”. Los términos relacionados con la violencia física fueron, “fracturas”, “romper” y “arrojar”; con la psicológica, “amenazar”, “miedo”, “vergüenza”, “lesión”, “secreción vaginal” y “vaginal”; con la financiera, “extracción”, “dependencia” y “agarrar”; con la negligencia, “falta”, “insumo” e “higiene”; con el abandono, “depresión”, “soledad” y “tristeza”.

Conclusión:

esta investigación enaltece la Enfermería como ciencia y profesión, especialmente en el área forense, al investigar la violencia contra las personas mayores. La percepción del enfermero hace que el proceso de enfermería sea más confiable y útil para identificar, informar y resolver casos.

DESCRIPTORES:
Adulto Mayor; Violencia; Abuso de Personas Mayores; Enfermería Forense; Atención de Enfermería

HIGHLIGHTS

Physical violence is more imminent than other forms.

Neglect and abandonment are interrelated among professionals.

Nursing professionals identify signs of violence.

INTRODUCTION

The increase in life expectancy of the population on a global scale has resulted in a quantitative increase in the number of people aged at least 60 years old. However, this growth has also been accompanied by various vulnerabilities faced by older adults¹, with the occurrence of Violence Against Older Adults (VAOA) standing out.

This problem is defined in the older adults’ statute as “any attitude that violates their rights through physical, psychological, financial and sexual aggression and neglect”^2:9. VAOA is more common among individuals aged between 60 and 69, female, brown-skinned, with low incomes and low schooling levels³.

It is important to note that the pandemic scenario caused by COVID-19 has led society as a whole to impose social isolation as one of the measures to prevent spread of the virus. However, this isolation has become more necessary for older adults, due to the possibility of more severe complications related to the age group. In the meantime, it was possible to observe that, at this public health moment, there was an increase from 267% to 567% in the number of VAOA cases⁴, raising further concerns in order to uncover the phenomenon and identify it as early as possible.

As it is a multifaceted phenomenon with implications in various social spheres, identifying VAOA represents a challenge for health professionals. A study⁵ conducted with the purpose of understanding the perspective of Nursing professionals working in Primary Care in relation to the prevention of violence revealed that some of them are able to suspect cases, although they are unclear about how to proceed in the face of the phenomenon.

Although there is diverse evidence about the impact of this social problem on older adults’ quality of life, there is still little awareness among Nursing professionals regarding the important role the profession can play. Identification of VAOA is frequently overlooked in health care because it is difficult for professionals to notice its indicative signs⁶.

From this perspective, as indispensable professionals in the care of any individual, nurses contribute to the detection of possible situations of violence, including psychological violence. Nurses need to be involved in the assessment process through anamnesis, seeking to collect as much relevant information as possible, observing the signs/symptoms that characterize the existence of mistreatment, in agreement with the multiprofessional team and as early as possible^5,7.

This study aimed at identifying the markers of violence against older adults from the nurses’ perspective.

METHOD

This is a qualitative study guided by the recommendations set forth in the Consolidated Criteria for Reporting Qualitative Research (COREQ) international guide, which contains 32 items for conducting qualitative research⁸.

The study was developed between June and September 2021 in the state of Paraíba (Brazil) with nine nurses in a Focus Group format in remote modality, due to the recommendations for social distancing related to COVID-19 in force at the time of data collection.

Focus groups are used in qualitative research studies that make it possible to discuss the theme under study with a minimum of five members and a maximum of fifteen⁹. Holding focus groups remotely has the benefits of low cost, secure data archiving and wide geographical coverage¹⁰.

The sample consisted of nine nurses using a non-probability snowball sampling technique. This type of sampling uses chains of references, meaning that the participants selected to take part in the study can refer new participants¹¹. The selection criterion was previous experience working and/or researching on the topic.

The curriculum vitae of each recommended participant was evaluated, and those with a background in health and those who carry out their care or academic duties in the following areas were invited: Forensic Nursing; Public Health; Collective Health; Geriatrics and Gerontology; and Abuse against older adults.

The first focus group was comprised by seven participants and lasted one hour and thirty-three minutes, covering issues related to physical, psychological and sexual violence. The same collaborators were invited to the second focus group; however, three reported unavailability in their schedules. Therefore, two alternates were invited to take part in the second round, making up six participants. This second stage lasted fifty-nine minutes, discussing financial violence, neglect and abandonment.

At the beginning of both focus groups, the study objectives were presented and the participants were invited to sign the Informed Consent Form (ICF) online. After signing, the focus group dynamics were explained. The participants were identified randomly and assigned numbers from one to nine.

In order to enable the group discussion, a fictitious clinical case related to each type of VAOA was read out and the participants were then asked to discuss the topic using the following guiding question: “Based on the case presented and your previous knowledge, which signs are suggestive of violence against older adults?”.

The data collected were transcribed in full and returned to the collaborators for qualitative validation of the content. In this stage, each participant read the focus group transcript and either totally agreed or altered the content by signaling changes. After the material was returned, the empirical content was transformed into a text corpus totaling 25 pages, and analyzed using the IRAMuTeQ (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires) software.

To carry out the analysis in the software, the text corpus complied with the instructions for text organization (monothematic, removal of questions and standardization of terms) and coding (speech start markers and use of underlines for compound terms). A similarity analysis was performed in order to identify the differential characteristics and connections between VAOA typifications, based on occurrences visualized using the maximum tree. The speech excerpts were identified by the type of violence followed by the participant’s number and according to the speech sequence, in order to preserve anonymity of the research collaborators.

The research in question was also enriched with a systematic and rigorous approach to data analysis, using Bardin’s content analysis methodology. This allowed for a more in-depth understanding of the phenomena under study and a solid foundation for the conclusions presented.

The research was approved by the Ethics and Research Committees of HULW/UFPB under opinion number 3,709,600 and of HUAL/UFCG under opinion number 3,594,339.

RESULTS

Through the similarity analysis it was possible to identify similarities and differences between the VAOA types and their respective indicators. Figure 1 shows the maximum tree with differentiation between colors, in which the central core is the term “violence”, identified in green.

Figure 1
Maximum tree of the similarity analysis for signs suggestive of VAOA among the nurses taking part in the study. Campina Grande, PB, Brazil, 2021.

In the aforementioned central core, the main suggestive signs of violence common to more than one typology were observed, such as the terms “cycle of violence”, “trust”, “dominate” and “psychological distress”. Eight branches emerged from the central core, distributed as shown in Figure 2.

Figure 2
Maximum tree of the similarity analysis for signs suggestive of VAOA among the nurses taking part in the study. Campina Grande, PB, Brazil, 2021.

The juxtaposition of the pink and yellow branches to the green (central) core refers to signs of physical violence with terms that express characteristics of this type of VAOA, such as “fractures”, “threats”, “break”, “throw” and “objects”. The following excerpts consist of the participants talking about physical violence.

The question of pushing, throwing an object at them, breaking their objects, taking something of theirs and throwing it on the floor, breaking it, for older adults, many times, for them, violence in itself is just when people go and slap them, pull their hair and hit them.(Nurse 09)

There could also be marks, scars on her body because she has a history of being threatened with melee weapons. So she could have been assaulted and she didn’t say anything, she didn’t give details. Yes, she could have a scar from a melee weapon. So that should be investigated too: possible fractures. (Nurse 02)

Also regarding the physical violence perceived in older adults, the branch referring to sexual violence was colored purple, also overlapping the larger central core and close to physical violence, indicating possible similarities in characteristics between the typifications. The differential characteristics of sexual VAOA, such as “vaginal”, “discharge”, “candidiasis” and “injury”, are noteworthy.

Presence of perineal injuries, genital bleeding, in men or women, and vaginal discharge. (Nurse 01)

The question of oral candidiasis, right? We have to take into account what is happening, because this older adult is going to have this oral candidiasis and imagine him having to report that these things are happening. (Nurse 07)

Psychological violence was centralized in the “mint green” branch, with attributes such as “threat”, “shame”, “fear”, “sleep” and “isolation”. The excerpts below confirm this.

The threats, the persecution issue also mentioned by the aggressor, that he will undertake this persecution; this also causes psychological distress, fear, right?, which she also mentions, and the question of interrupting her life, socializing, relationships with other people. (Nurse 02)

He would threaten her and spend the night sitting on a chair, threatening her and her children, afraid to go to sleep; when he hit her she knew that it was the end. (Nurse 07)

Neglect and abandonment are interrelated in the maximum tree and reflect the theoretical approximation between both types. In this way, the indications mentioned by the participants that meet the discussion of abandonment are evidenced by the terms “loneliness”, “depression”, “sadness” and “emotional”, as can be seen in the testimonies below.

Depression and loneliness in abandonment, in my opinion, bring more intense emotional signs, but not that this doesn’t also happen in neglect. (Nurse 02)

Older adults don’t feel unwanted or rejected, they feel alone. (Nurse 04)

On the other hand, the participants mentioned neglect with presence of characteristic signs made evident by the terms “lack”, “absence”, “supply” and “hygiene”, as clarified by the testimonies below.

So every time I read or hear something about neglect, especially of older adults, it’s a very broad term. If we take the concept into account, it’s precisely that lack, absence, refusal.(Nurse 03)

Lack of care, omitting hygiene care. For example, we see a house where the family has relatively good financial conditions and we see that the older adult is somewhat poorly dressed, their appearance, oral hygiene issues and general poor hygiene are indicative.(Nurse 01)

In the presentation of the red branch corresponding to the intermediate maximum tree, financial violence (blue) and the aforementioned neglect and abandonment, when terms such as “dependence”, “autonomy”, “alone” and “care” are observed along with the participants’ discourse, it is possible to see that they are risk conditions for the occurrence of both VAOA typologies.

I think it’s similar to financial dependence, from the moment that, for example, they have some functional dependence. And then he needs others to provide care, and these other people can take advantage of his income for other issues and not help with this functional dependence. (Nurse 01)

There’s an older adult who lives alone, even the community health worker can see, “well that older adult over there doesn’t have a family member with him”, nobody shows up, he lives alone, he has chronic diseases, he needs help. (Nurse 02)

Also regarding financial violence, at the end of the tree (in blue), it can be seen that the terms “withdrawal”, “support (v)”, “money”, “bank” and “pay” refer to financial violence. The testimonies below show the way in which these signs are presented.

We come across situations not only like this, but where older adults are scammed by people taking out loans in their name without their authorization. So the older adult can’t get around. So, many times, someone else is responsible for making the withdrawal, even though they have to update it periodically, go to the bank to register their fingerprint and update it.(Nurse 04)

The older adult says he can’t afford medications and sometimes the nurse just lets it pass, without asking the reason why. Could it be that he can’t afford it just because he doesn’t have enough money? Or because someone is taking his money, if he’s losing part of his money because he’s paying off someone else’s loan, or if he’s supporting someone else. (Nurse 06)

DISCUSSION

The VAOA outcomes can have a series of social, health and individual impacts, as evidenced by the comprehensive analysis carried out. The psychological distress experienced by older adults can be manifested by presence of psychological disorders, including depression¹², which in turn can progress to situations such as suicidal ideation¹³ and result in death in more serious cases.

The cycle of violence is widely discussed from the perspective of violence against women. However, the need to break the cycle permeates all age groups, either by the victim or through effective public policies that provide them with the tools and support to do so. Nursing care based on recognizing the needs of older adults in situations of violence will provide them with support in identifying violent cycles, thus enabling professionals to be active in the support network in the process of breaking the violent cycle^5,7.

The physical aspects involved in identifying the type of physical violence include noticing visible marks identified on the victim’s body¹⁴. The nurses that took part in the research indicated a few, as evidenced above. However, other signs of physical violence can be observed, such as burns¹⁵, scratches¹⁶, pushing and, in more serious cases, punches, blows⁵ and beatings¹⁷.

Signs suggestive of physical violence will require health professionals to look more closely at the characteristics of physical violence, especially in order to understand the aspects involved in the violent situation, whether it was use of a firearm, a melee weapon or merely the perpetrator’s physical strength. In addition, the professionals will need to investigate other possible lesions that are imperceptible to the naked eye, as well as the general appearance of the older adults, such as malnutrition and poor physical hygiene¹⁸.

Sexual violence against older adults is defined as “sexual acts or games of a homo- or hetero-relational nature that use aged individuals to obtain arousal, sexual intercourse or erotic practices through enticement, physical violence or threats”^19:2. Thus, while identifying signs suggestive of its occurrence, the professionals can identify the presence of perineal lesions or vaginal discharge suggestive of Sexually Transmitted Infections (STIs), as mentioned by “Nurse Seven”, a research collaborator.

It is necessary to emphasize that, when it comes to discussing violence within the Unified Health System (Sistema Único de Saúde, SUS), any type of violence is compulsorily notifiable. However, sexual violence is of immediate compulsory notification²⁰ in view of the multiple consequences it can cause.

In addition to the findings mentioned by the research participants, biological residues such as semen can be observed during the physical examination of a sexual violence victim. It is fundamental that while handling of the patient or the scene where the violent act took place, nurses take care to maintain the traces so that the material collected is not compromised²⁰.

From the perspective of psychological violence, it is crucial to note that this is the most prevalent form of violence, although it is also the most challenging to identify. Experiencing situations of psychological violence by older adults can result in significant harms to their quality of life, as mentioned by one of the nurses interviewed. In addition to changes in sleep patterns, other consequences include fatigue, increased heart rate and difficulties in personal relationships and concentration^15-17,19.

The occurrence of events such as insults, name-calling and gestural aggression that compromise a person’s image or self-esteem can be characterized as psychological violence. Outcomes such as depression, suicidal ideation and identity crisis are characteristic of older adults who are victims of psychological violence²¹.

In this sense, it is important to consider the behavioral aspects shown by the aged individuals during the consultations, in order to identify this type of violence. Older adults may show a tendency towards introversion and face difficulties in interpersonal relationships within their usual social circle, as well as displaying different behaviors in the presence of the aggressor⁵.

It is imperative to emphasize that, in relation to neglect and abandonment, although there is a theoretical approximation, abandonment is a consequence of older adult’s helplessness, who lack protection from their legal guardians, be them family members, institutions or society in general. On the other hand, neglect stems from the failure to provide fundamental care for older adults’ health¹⁹.

The family has the main legal responsibility for aged people, both in terms of their health and of their affections²². This premise is corroborated by the observations made by the nurses that comprised the sample, who pointed out that abandonment can be identified through the affective and emotional aspects present in each older adult, such as manifestations of depression, feelings of loneliness and the sensation of being unwanted or rejected.

However, it is important to point out that abandonment can also manifest itself in the care provided to older adults by professionals from different care areas, as well as in macro-social dimensions. This includes situations of omission or desertion on the part of governmental bodies when it comes to providing assistance, protection and security, aggravating older adults’ vulnerability^17,22-23.

Neglect is a type of violence in which basic needs are not met, such as adequate diet, decent shelter, hygiene and care for older adults²⁴. Although it seems difficult in the literature to distinguish it from self-neglect, neglect refers to something suffered by older adults but perpetrated by a third party²⁵. In self-neglect, aged individuals themselves are the perpetrators of self-violence.

In a research study conducted with 281 older adults in the Chinese province of Anhui, 80.4% reported that they had suffered neglect more than three times and 34.9% had undergone it twice, one of the reasons being lack of attention, especially to aged individuals who required more care²⁶. When older adults are affected by this type of violence, they are at a greater risk of losing everyday skills such as eating, going to the toilet, taking medications as prescribed and managing their finances, making them more dependent²⁵.

In order to combat this practice, the Nursing team (especially nurses) plays a crucial role in the violence experienced by older adults, having the ability to properly identify the type of mistreatment and/or neglect and guaranteeing maintenance of their health, which in most cases is already more frail due to the aging process itself. Precisely because they have certain physiological characteristics, the professionals need to have a shrewd eye in order to be able to assess and differentiate the signs and symptoms resulting from mistreatment or not^5,7.

Older adults are highly vulnerable and susceptible to financial exploitation. Although intrinsic to aging, cognitive decline and decision-making deficits are risk factors for financial violence. Financial violence is defined as the illegal or improper use of an older adult’s assets, property or money, including theft and fraud, by someone known to them or a stranger²⁷.

The incidence of this type of violence is becoming increasingly prevalent and noticeable to aged people²⁷. Corroborating this, a study carried out in Brazil with 555 Police reports revealed 58.9% of financial abuse²⁸. This finding is similar to a survey of 510 victims in Portugal, which evidenced that 47.5% had suffered financial violence²⁹.

Despite the growing incidence, reporting this abuse is still a barrier, especially if the perpetrator is a family member, friend or acquaintance. The victims are reluctant because of fear of getting into trouble, of discrediting the authorities and of having some link with the abuser. After eight years of research, American researchers contacted the victims and 87.5% of those who stated that they had experienced events perpetrated by family members/friends did not report the crime to the authorities³⁰.

It is indispensable to emphasize that the professionals’ statements indicate the urgency of creating an instrument that can support the approach to the phenomenon of violence, covering all its types and natures. This tool should be used during Nursing consultations with the purpose of easing the identification of potential risks for the occurrence of violence, as well as the confirmation of specific situations for each typification.

Due to the pandemic, data collection took place in a virtual environment, which may have limited the ability to delve deeper into uncover nuances of the phenomenon from the professionals’ point of view.

FINAL CONSIDERATIONS

The empirical material, which came from the collaboration of the nurses that took part in the study, made it possible to identify the main suggestive signs observed to identify situations of violence against older adults. Although the in-depth analysis of each type of violence is extremely broad, the data made it possible to see the main axes and signs of violence in a generic way and, more specifically, for each type of violence from the Nursing professionals’ perspective.

Through the maximum tree it was possible to perceive the central core of identification of violence, which is strongly related to psychological distress, the cycle of violence and trust, which are characteristics that permeate the other forms of violence identified in the tree branches. The professionals are able to identify significant markers in terms of suggesting the occurrence of violence against older adults.

In short, this research enhances and strengthens Nursing as a science and profession, especially in the Forensic Nursing area, by exploring the nurses’ view of violence against older adults, a topic that is little discussed in the forensic literature. Based on the nurses’ perception, operationalization of the Nursing Process becomes more reliable and applicable for the care to be provided in cases of violence against older adults.

ACKNOWLEDGMENTS

This paper was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, CAPES) - Funding Code 001.

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• *
  Article extracted from the doctoral thesis: “EVIDÊNCIAS DE VALIDADE DE ESCALA PARA RASTREIO DA VIOLÊNCIA CONTRA PESSOA IDOSA”, Universidade Federal da Paraíba, João Pessoa, PB, Brasil, 2023.

Edited by

Associate editor:

Dra. Juliana Balbinot Reis Girondi

Publication Dates

• Publication in this collection
  22 July 2024
• Date of issue
  2024

History

• Received
  17 July 2023
• Accepted
  07 Mar 2024