SPECIALIZED TERMINOLOGY FOR NURSING PRACTICE WITH OLDER ADULTS IN SITUATIONS OF VIOLENCE

TERMINOLOGÍA ESPECIALIZADA PARA LA PRÁCTICA DE ENFERMERÍA A ADULTOS MAYORES EN SITUACIÓN DE VIOLENCIA

ABSTRACT

Objective:

to develop a term bank for nursing clinical practice addressing violence against older adults, based on scientific literature.

Method:

this is a methodological, documentary study conducted in the following steps: identification of relevant terms for the target population and/or health priority, extracted from a scoping review using the PorOnto tool; and cross-mapping of the identified terms with those from the 2019/2020 version of the International Classification for Nursing Practice. The Content Validity Index was used for term validation. Variables related to participants were analyzed using descriptive statistics.

Results:

a total of 1,236 terms were identified, which were reduced to 704 after validation by seven judges. Subsequently, through cross-mapping, 293 terms were found to be present and 411 absent in the International Classification for Nursing Practice version 2019/2020.

Conclusion:

the study’s contributions emphasize the importance of strengthening specialized terminologies that address the needs of older adults in situations of violence. This term bank will support the development of new nursing diagnoses, outcomes, and intervention statements to enhance the care plan provided by the nursing team across all levels of complexity.

DESCRIPTORS:
Nursing; Controlled Vocabulary; Nursing Process; Older adult; Violence

RESUMEN

Objetivo:

desarrollar una base terminológica para la práctica clínica de enfermería frente a la violencia contra adultos mayores, fundada en la literatura científica.

Método:

estudio metodológico, documental, desarrollado a través de las etapas de identificación de términos relevantes para la clientela y/o prioridad de salud, extraídos de una revisión de alcance utilizando la herramienta PorOnto; y mapeo cruzado de términos identificados con términos de la Clasificación Internacional para la Práctica de Enfermería versión 2019/2020. Para validar los términos se utilizó el Índice de Validez de Contenido. Las variables relacionadas con los participantes se analizaron mediante estadística descriptiva.

Resultados:

se identificaron 1.236 términos, que resultaron en 704 después de la validación por siete jueces. Luego, con mapeo cruzado, se identificaron 293 términos constantes y 411 términos no constantes en la Clasificación Internacional para la Práctica de Enfermería versión 2019/2020.

Conclusión:

se destacan las contribuciones del estudio para el fortalecimiento de terminologías especializadas y adecuadas a las necesidades de las personas mayores en situación de violencia. Esta base terminológica contribuirá a la construcción de nuevos enunciados de diagnósticos, resultados e intervenciones de enfermería para calificar el plan de cuidados realizado por el equipo de enfermería en todos los niveles de complejidad.

DESCRIPTORES:
Enfermería; Vocabulario controlado; Proceso de enfermería; Adulto mayor; Violencia

RESUMO

Objetivo:

desenvolver um banco de termos para a prática clínica de enfermagem frente à violência contra a pessoa idosa, a partir da literatura científica.

Método:

estudo metodológico, documental, desenvolvido mediante as etapas de identificação dos termos relevantes para a clientela e/ou prioridade de saúde, extraídos de uma scoping review pela ferramenta PorOnto; e mapeamento cruzado dos termos identificados com termos da Classificação Internacional para a Prática de Enfermagem versão 2019/2020. Para validação dos termos, foi utilizado o Índice de Validade de Conteúdo. As variáveis relativas aos participantes foram analisadas por meio de estatística descritiva.

Resultados:

foram identificados 1.236 termos, que resultaram em 704 após validação por sete juízes. Em seguida, com o mapeamento cruzado, foram identificados 293 termos constantes e 411 não constantes na Classificação Internacional para a Prática de Enfermagem versão 2019/2020.

Conclusão:

sublinha-se as contribuições do estudo para o fortalecimento de terminologias especializadas e adequadas às necessidades da pessoa idosa em situação de violência. O referido banco subsidiará a construção de novos enunciados de diagnósticos, resultados e intervenções de enfermagem para qualificar o plano de cuidados conduzido pela equipe de enfermagem em todos os níveis de complexidade.

DESCRITORES:
Enfermagem; Vocabulário Controlado; Processo de Enfermagem; Idoso; Violência

INTRODUCTION

Violence Against Older Adults (VAOA) is a complex phenomenon with various implications for the health of older adults and their families. Despite the expansion of discussions and published studies on this topic in recent years^1-2, efforts to prevent and combat the cycle of violence face challenges due to factors such as underreporting and omission of cases³.

Thus, the presence of older adults in health care facilities presents an opportune moment for detecting and reporting violence. Nurses, with a keen awareness of this situation, should utilize the nursing process to outline care planning and make the necessary communications for case monitoring4.

The Nursing Process (NP) stimulates critical and clinical reasoning, reinforces professional commitment to patient care, streamlines the work process, and enhances practice based on the population's needs5. Given that this methodological tool is used to provide care to all people, including families and communities in various health-disease process scenarios, it is essential to incorporate the NP into all nursing specialties, particularly forensic nursing.

Forensic Nursing is a specialty that integrates nursing science with forensic sciences in the application of the nursing process to care for victims of violence, accidents, or other traumas in both public and legal contexts6. In addition to implementing preventive and therapeutic measures, the forensic nurse is skilled in the preservation, collection, documentation, and storage of evidence4.

As violence is increasingly recognized as a public health issue due to its multifaceted etiology and outcomes, nursing must rely on the expertise of both the nursing science and the forensic specialty to provide individualized and humanized care, focusing on the prevention and management of violence cases7.

It is noteworthy that there is no specific care tool linked to the nursing process for older adults experiencing violence. Consequently, there is a need to develop and validate instruments that assist nurses in implementing the nursing process tailored to older adults in situations of violence. The use of nursing terminologies is recommended by international organizations and aids in the organization and systematization of care, given the standardization of vocabulary and the consolidation of care standards.

The International Classification for Nursing Practice (ICNP^®) is an enumerative, combinatory, and specialized terminology with a structural organization of concepts and definitions that facilitates clinical reasoning and, consequently, care documentation8.

By using this terminology, nurses base their practice on a set of scientific knowledge, applying a globally recognized classification to promote, prevent, and intervene with clients. In this case, older adults in experiencing violence9.

However, the literature reveals a lack of classifications for all specific areas of nursing practice, particularly on the mentioned topic. Therefore, it is necessary to collect data and code terms that support the development of terminological subsets, characterized by the combination of nursing diagnosis, outcome, and intervention statements tailored to a specific specialty or unique population9. This is a proposal recommended by the International Council of Nurses (ICN) to enhance clinical practice and expand the applicability of the ICNP^® in any country where this terminology is used, considering its attribute as an enumerative terminology8^,10. Thus, the objective of this study was to develop a term bank for nursing clinical practice in response to VAOA based on scientific literature.

METHOD

This is a methodological, documentary study developed according to the method for developing terminological subsets, which includes the steps of identifying relevant terms for the target population and/or health priority, and cross-mapping the identified terms with terms from the ICNP^® Version 2019/202011.

For the methodological framework, the study utilized the results of a scoping review12, ICNP^® Version 2019/2020, and an analysis of the degree of equivalence according to the International Organization for Standardization (ISO) TR 12.330:201613.

In the first stage, a literature search was conducted to identify relevant terms for nursing practice in caring for older adults in situations of violence. The identification and analysis of relevant terms were carried out between July and December 2021. The validation of the terms by experts took place between May and September 2022. For data collection, an online form (Google Forms) with 14 questions, designed by the authors, was used. The terms were sent in an Excel spreadsheet, where the experts were asked to mark what they deemed appropriate for validation. It is important to note that each term included a blank field for additional observations.

This step was conducted based on the results of a scoping review12, in accordance with the Joanna Briggs Institute (JBI) guidelines on nursing care for older adults in situations of violence. The study was carried out by members of the Research and Study Group in Forensic Nursing (GEPEFO-UFPB).

Initially, 17,378 studies were identified. After reviewing the titles, 140 were selected for full-text reading. During the document assessment stage, 29 studies were relevant to the topic; however, 18 studies addressed the review's objective. One study was added after analyzing the references, bringing the final sample to 19 articles (14 qualitative and 5 quantitative)12.

After obtaining the 19 articles, all foreign language publications were translated into Portuguese using an online translation tool. The texts were compiled into a single Word^® document, and information such as section titles, authors, abstracts, methodologies, footnotes, references, appendices, and annexes were removed. This document was exported to Portable Document Format (PDF) and named “Artigos_Revisão.” It served as the final textual corpus to be extracted by the semi-automatic ontology construction tool in Portuguese, called PorOnto14.

PorOnto processed the terms, which were then exported to an Excel^® spreadsheet titled “Resultados PorOnto,” containing 10,731 terms. Following this process, the terms underwent normalization and standardization, including graphic corrections, adjustments in gender, number, and degree, and the removal of duplicates, resulting in a total of 1,236 terms organized in alphabetical order.

The terms were further assessed by experts who are members of GEPEFO-UFPB, researchers in the field of violence against older adults, and holders of specialist titles in forensic nursing and/or gerontological nursing. The participation of these experts underscores the importance of confirming the term relevance in the development of nursing diagnoses, outcomes, and interventions11.

Next, the terms were validated regarding their utility in clinical practice and relevance to nursing practice in caring for older adults in situations of violence.

For the validation of the terms by experts, the Content Validity Index (CVI) was used, which measures the proportion of agreement among judges regarding the instrument and its items15. The CVI is typically used with a Likert scale, with responses ranging from 1 to 4. However, in this study, a method was adopted that divides the items into dichotomous responses, where 1 = totally irrelevant and 4 = totally relevant16.

Validated terms were included if they met an acceptable index of at least 0.83 based on the number of experts17, and items with lower values were excluded from the term bank. SPSS software was used to analyze sociodemographic variables through descriptive statistics and absolute and relative frequency.

The selection of experts followed the criteria established by Guimarães et al.18, as illustrated in Chart 1. Based on these criteria, a score is assigned to classify individuals as junior experts, with a minimum score of 5 points and at least four years of clinical experience in the field; master experts, with a score between 6 and 20 points; and senior experts, with a score above 20 points. Each researcher then decides the required level to achieve the study's objectives. In this study, experts were required to achieve a minimum score of 5 points. It is noteworthy that the ICN does not provide specific criteria for the experts selection, leaving the definition of such criteria to the discretion of the researchers.

Chart 1 -
Criteria for Judge Selection, according to Guimarães et al. (2016). João Pessoa, PB, Brazil.

Criteria	Score
At least four years of clinical experience in the specific area (mandatory)	04
At least one year of experience in clinical practice and teaching in the specific area, and teaching nursing classifications	01
Research experience with published articles on nursing classifications in reference journals	01
At least two years of participation in a research group in the specific area	01
Doctorate/PhD in nursing in the specific area	02
Master's degree in nursing in the specific area	01
Nursing residency in the specific area	01

After analyzing the criteria, 31 invitation letters were sent to nurses. Out of the 31 invited, two were unavailable to participate, ten accepted the invitation, and seven completed the term bank instrument, forming the final validation sample.

An Invitation Letter was sent to the selected judges' email addresses, providing information about the study, including objectives, methodological steps, and justification. After obtaining the judge's consent, an online form was sent, which included the Informed Consent Form (ICF), a questionnaire to characterize the sample, and the term bank for validation. Regarding the validation instructions, participants were asked to indicate whether they agreed or disagreed with the terms for the care of older adults in situations of violence. In cases of suggestions or necessary changes, a comment section was provided for each item.

The terms designated for content validation were included in an Excel spreadsheet and sent along with a Google Form for characterizing the experts' sample.

The spreadsheet containing the validated terms was imported into Access for Windows to carry out the second stage of the study, which involved cross-mapping the identified terms with those from ICNP^®, Version 2019/2020. Cross-mapping is a methodological process that allows for the identification of convergences and divergences between terms, with corresponding data analysis, to provide an explanation for something not available in the literature19. Through cross-mapping, terms that are present and absent in ICN^® for nursing practice in caring for older adults in situations of violence were identified.

Additionally, the equivalence level of terms not found in ICNP^®, was established according to ISO TR 12330:2016, which provides a scale for evaluating meanings as follows: Degree 1- Lexical and conceptual meaning equivalence; Degree 2 - Meaning equivalence, but with synonymy; Degree 3 - The source concept is broader and has less specific meaning than the target concept/term; Degree 4 - The source concept is narrower and has more specific meaning than the target concept/term; Degree 5 - No mapping is possible13. Following the guidelines of the aforementioned ISO, when a non-constant source concept was judged by the expert nurses as Degree 1 or 2, it was replaced by the equivalent concept in ICNP^®, thus becoming considered a constant term in ICNP^®. Terms classified as Degree 3, 4, and 5 were retained as non-constant terms in ICNP^® and organized within the Seven-Axis Model of ICNP^®, following the guidelines of the Brazilian method. After this process, the term bank for nursing practice with older adults in situations of violence was established.

This research is part of a project submitted to the Human Research Ethics Committee of UFPB, under opinion No. 3.709.600. Ethical aspects concerning the protection of participants in scientific research involving human subjects were adhered to, in accordance with Resolution No. 466, dated December 12, 2012, by the National Health Council.

After explaining the research objectives, maintaining confidentiality, ensuring participants' anonymity, and their right to choose participation, the judges were asked to sign the ICF. This marked the beginning of the validation process for the terms developed in this study, contributing to the development of standardized language for nursing practice in addressing VAOA.

RESULTS

Regarding the judges' characteristics, 85.7% were women (n=6), with an average age of 47.4 years old (SD ± 11.2). Among them, 71.4% held a doctoral degree as their highest qualification (n=5) and had an average of 23.6 years of professional experience (SD ± 13.9). Additionally, 71.4% were currently in teaching positions (n=5)

Concerning their experience as authors or advisors in studies on the themes related to VAOA, nursing terminologies focusing on ICNP® and the nursing process, 71.4% reported having produced scientific articles (n=5). Additionally, 71.4% were or had been involved in research groups/projects related to nursing terminologies, VAOA, and the nursing process (n=5), and 85.7% had used or were using ICNP® in their professional practice (n=6).

The 1,236 terms identified in the first stage of the study were sent for validation, and 440 of these were excluded for having a CVI<0.83. As a result, 796 terms were retained (CVI ≥ 0.83). After cross-referencing with the terms from ICNP^® version 2019/2020, analyzing the degree of equivalence, and excluding repeated terms, the final sample consisted of 704 terms, with 293 being constant and 411 non-constant.

Among the terms included in ICNP® 2019/2020, 146 belonged to the Focus axis, 22 to the Judgment axis, 65 to the Action axis, 26 to the Means axis, 18 to the Location axis, 7 to the Client axis, and 9 to the Time axis. This group of terms originated from the results of equivalence analyses 1 and 2, and is presented in the sample excerpt of terms (Chart 2).

Chart 2 ‒
Relevant terms for nursing practice with older adults in situations of violence, classified as included in ICNP^® 2019/2020. João Pessoa, PB, Brazil, 2022-2023.

Axes	Constant Terms
Focus	Abandonment; Alcohol Abuse (or Alcoholism); Screening Follow-up; Agitation; Anguish; Anxiety; Learning; Skill Learning; Attention; Attitude; Self-control; Self-care; Self-esteem; Self-image; Self-monitoring; Autonomy; Chill/Shiver; Capacity; Characteristic; Shock; Wound Healing; Cognition; Complication; Behavior; Aggressive Behavior; Self-destructive Behavior; Communication; Condition; Hemodynamic Condition; Psychological Condition; Trust; Confidentiality; Comfortable; Comfort; Confusion; Knowledge; Awareness; Consent; Continuity; Control; Contusion; Religious Belief; Crime; Crisis; Guilt; Dementia; Discomfort; Hopelessness; Despair; Dehydration; Malnutrition; Civil Disobedience; Discrimination; Disposition (or Readiness); Pain; Edema; Side Effect; Elimination; Emaciation; Emotion; Coping/Confrontation; Aging; Balance; Hope; Stress; Ethnicity; Physical Examination; Fatigue; Phenomenon; Wound; Feces; Hunger; Heart Rate; Frustration; Hematoma; Hypertension; Hypothermia; Hostility; Mood; Identity; Impotence; Impulse; Disability (or Limitation); Infection; Infrastructure; Restlessness; Insecurity; Integrity; Social Isolation; Laceration; Law; Injury; Emotional Bond; Fear; Memory; Urination; Death; Nausea; Need; Denial; Foul Odor; Orientation; Spousal Role; Parental Role; Perception; Belongings (or Possessions); Politics; Worry; Pressure; Privacy; Procedure; Process; Family Process; Intentional Process; Fall; Burn; Accomplishment; Regimen; Sexual Relation; Relationship; Income; Resistance; Result; Routine; Blood; Health; Service; Self-help Service; Sign; Symptom; Socialization; Suffering; Loneliness; Suffocation; Suicide; Trend; Trauma; Sadness; Shame; Surveillance; Bond; Violence; Vision; Victim; Older Adult Victim of Abuse; Sexual Assault Victim (or Rape).
Judgment	High; Delayed (or Slow); Low; Complexity; Dependence; Effective; Prescription Status; Extent; Degree; Severity; Independence; Interrupted; Judgment, Positive or Negative; Mild; Moderate; Small; Impaired/Harmed; Presence; Progress; Real; Risk; Size.
Action	Advocate; Analyze; Support; Attend; Increase; Assist; Evaluate; Collaborate; Collect; Check; Confirm (or Prove); Contact; Care (or Take Care); Demonstrate; Describe; Determine; Distribute; Document; Elevate; Encourage; Establish; Stimulate; Examine; Execute; Explain; Facilitate; Speak; Ensure (or Assure); Manage; Guide; Identify; Inform; Insert; Interpret; Interrupt; Manipulate; Maintain; Mediate; Measure (or Verify); Minimize; Mobilize; Monitor; Motivate; Notify; Observe; Obtain; Offer; Direct; Listen; Allow; Plan; Position; Prepare; Prescribe; Prevent; Prioritize; Promote; Protect; Provide (Supply, Furnish); Reinforce; Record; Report; Request (or Require); Restrict (or Contain); Trace (or Track).
Means	Food; Analgesic; Social Worker; Wheelchair; Bed; Wound Dressing (or Bandage); Device; Drug; Nurse; Interprofessional Team; Gloves; Material; Medication; Doctor; Plan; Care Plan; Patient Record; Protocol; Meal; Emergency Service; Nursing Service; Health Promotion Service; Solution; Technique; Telephone; Therapy.
Location	Joint (Articulation); Nursing Home; Arm; Head; Hair; Oral Cavity (or Mouth); Clinic; Body; Nurse (Ward); Face; Hospital; Lower; Home; Breast; Hand; Middle; Neck; Position.
Client	Community; Caregiver; Family; Group; Elderly; Individual; Patient.
Time	Admission; Conference (or Group Conversation); Meeting; Event or Episode; Examination; Frequency; Hospitalization; Week; Situation.

The Chart 3 illustrates the non-constant terms; 217 were in the Focus axis, 78 in the Judgment axis, 28 in the Action axis, 53 in the Means axis, 13 in the Location axis, 17 in the Client axis, and 5 in the Time axis (Chart 3).

Chart 3 -
Relevant terms for nursing practice with elderly people in situations of violence, classified as non-constant in ICNP^® 2019/2020. João Pessoa, PB, Brazil, 2022-2023.

Axes	Non-existing terms
Focus	Family Abandonment; Elder Abuse by Caregivers; Emotional Abuse; Financial Abuse; Physical Abuse; Psychological Abuse; Verbal Abuse; Activation of Assistance Services; Abusive Actions; Follow-up; Illness; Affection; Aggravation; Physical Assault; Psychological Assault; Verbal Assaults; Coercion; Alienation; Assistance; Appearance; Retirement; Appropriation; Approach; Argument; Housing Arrangement; Aspect; Attention to Violence Identification; Care/Service; Activity; Daily Activities; Friction; Absence; Self-assessment; Self-knowledge; Self-neglect; Elder Self-neglect; Self-sufficiency; Assistance; Assessment; Abuse Risk Assessment; Bathing; Barrier; Well-being; Benefit; Biopsychosocial; Search; Custody Chain; Campaign; Fatigue; Case; Cause; Caution; Scenario; Censorship; Chance; Cycle; Violence Cycle; Circumstance; Classification; Clinical; Collaboration; Collection; Risk Behavior; Impairment; Commitment; Verification; Conflict; Embarrassment; Contact; Context; Counter-reference; Contribution; Coexistence; Living Together; Coordination; Care; Damage; Defense; Disability; Cognitive Deficit; Depression; Description; Development; Disorder; Diagnosis; Decrease; Right; Availability; Documentation; Disease; Effect; Empowerment; Illness; Understanding Violence; Government Entity; Involvement; Education; Effort; Stereotype; Stimulation; Rape; Etiology; Evidence; Evidence of Abuse; Exclusion; Exercise; Experience; Exploitation; Risk Factor; Flow; Strength; Forms of Violence; Fragility; Gender; Generation; Geriatrics; Management; Heritage; Hydration; Hygiene; Environmental Hygiene; History; Age; Identification; Violence Identification; Implementation; Importance; Imposition; Inclusion; Incontinence; Indication; Influence; Insertion; Institutionalization; Integration; Intensity; Interest; Intergenerationality; Interpretation; Intersectoral; Intervention; Intimidation; Intimate; Intolerance; Investigation; Survey; Cleaning; Language; Stain; Management; Manifestation; Maintenance; Marginalization; Male; Neglect; Neglect of Older People; Nutrition; Observation; Offense; Omission; Pattern; Participation; Pathology; Loss; Profile; Permanence; Perpetration; Perspective; Practice; Preparation; Preservation; Priority; Deprivation; Promotion; Protection; Punishment; Quality; Complaint; Screening; Reaction; Adjustment; Recommendation; Symptom Recognition; Reference; Regulation; Reorganization; Reorientation; Rest; Resolution; Respect; Responsibility; Retention; Satisfaction; Older Adults Health; Sensation; Feeling; Confidentiality; Silence; Violence Indicator; System; Request; Substance; Suggestion; Support; Suspected Violence; Tension; Attempt; Typology; Tolerance; Violation; Structural Violence; Financial Violence; Physical Violence; Psychological Violence; Sexual Violence; Vulnerability; Insult.
Judgment	Abusive; Aggressive; Threatened; Threatening; Retired; Risky; Assistive; Assisted; Attended; Attentive; Mitigating; Self-neglectful; Self-inflicted; Self-sufficient; Beneficial; Collaborative; Collective; Conflicting; Confrontational; Marital; Deficient; Dependent; Unknown; Dehydrated; Disoriented; Domestic; Emotional; Stressors; Fatal; Financial; Physical; Fragile; Functional; Geriatric; Gerontological; Degree of Vulnerability; Hygienic; Holistic; Impotent; Disabled; Incapable; Ineffective; Unhappy; Informative; Dissatisfied; Insecure; Integrated; Whole; Intense; Interactional; Interpersonal; Intimidated; Intimidating; Irritated; Isolated; Latent; Moral; Negative; Mandatory; Observed; Hidden; Property-related; Positive; Potential; Violence Potential; Early; Professional; Prolonged; Own; Psychological; Psychosocial; Psychiatric; Repeated; Sexual; Alone; Violent; Vulnerable.
Action	Alert; Threaten; Store; Update; Report; Discuss; Distinguish; Emphasize; Humanize; Incorporate; Interfere; Equip; Intervene; Empower; Propose; Provide; Adjust; Reevaluate; Recommend; Recognize; Depict; Raise Awareness; Systematize; Suggest; Suspend; Witness; Verify; Facilitate.
Means	Holistic Approach; Individual Approach; Interdisciplinary Approach; Police Station Activation; Violence Prevention Actions; Health Promotion Actions; Reception; Medication Administration; Help; Medical History; Notation; Seat; Specialized Assistance; Bandage; Nursing Assistant; Conduct; Consultation; Report; Testimony; Document; Education; Referral; Geriatric Nursing; Gerontological Nursing; Interview; Nursing Team; Family Health Team; Elderly Statute; Family Health Strategy; Geriatrician; Instrument; Interdisciplinary; Intrafamilial; Legal; Stretcher; Medication; Message; Multidisciplinary; Multiprofessional; Notification; Mandatory Notification; Police Officer; Prevention; Violence Prevention; Proposal; Evidence; Protection Networks; Nursing Record; Medicine; Clothing; Subsidy; Torture; Treatment.
Location	Domestic Environment; Family Environment; Hostile Environment; Basic Attention; Primary Care; Elderly Police Station; Home; Church; Location; Medium; Residence; Urinary Tract; Ankle.
Client	Abuser; Companion; Community Health Agent; Aggressor; Author; Authority; Clientele; Partner; Spouse; Child; Son-in-law; Man; Husband; Woman; Population; Witness; User.
Time	Daily; Hourly; Monthly; Previous; Temporary.

DISCUSSION

Regarding the terms under the Focus Axis, the term "Aggressive Behavior" stands out. Since violence involves an act of aggression, a nurse's perception of aggressive behavior from the perpetrator towards the elderly person is crucial for early detection of violence and the development of an effective care plan, especially concerning psychological and financial aspects. During nursing care, it is possible to recognize the perpetrator's actions related to control, deprivation, intimidation, threat, manipulation, and trivialization of the elderly person20.

The terms Contusion, Pain, Hematoma, Fall, and Burn may serve as significant markers for identifying physical violence against the older adults. A national study analyzing the profile of VAOA cases in urgent and emergency services found that physical violence was present in 85% of records, with physical force used on elderly women and sharp objects used on men21. Therefore, it is crucial for nurses to be vigilant in the physical examination to identify injury types associated with violence and to carefully listen to the elderly person's account during the anamnesis, in order to involve the appropriate sectors and ensure timely protection and assistance for the victims.

Within the Focus axis, the term ‘’Older Adult Abuse Victim’’ is directly related to the phenomenon of interest in this study. Given that VAOA is a public health issue, the inclusion of this term in the ICNP^® aligns with the need for nursing attention, requiring nurses to possess skills in violence prevention, appropriate management to address the specific needs of elderly individuals, and therapeutic intervention in such cases.

The term "Risk," found in the Judgment axis, can refer to the possibility of an older adult experiencing violence, as well as the need for nurses to be vigilant about risk factors associated with VAOA, such as gender, income, education level, living arrangements, and comorbidities22.

In the Action axis, the terms "Collect" and "Document" align with the competencies of forensic nursing after identifying a case of violence4. Collecting evidence and documenting it ensure the preservation of evidence and the reliability of nursing care. Additionally, other notable terms include "Monitor," "Notify," "Observe," "Listen," and "Trace" (or "Track"). These terms can guide relevant interventions for planning care, ranging from anamnesis, including observation and active listening for preliminary screening of VAOA, to mandatory reporting and case monitoring.

In the Means axis, the terms "Nurse" and "Care Plan" underscore the importance of nursing professionals in planning care against violence. The care plan is central to the nurse’s practice and can be mediated through activities such as anamnesis, physical examination, monitoring of victims and perpetrators, intra- and intersectoral coordination, and implementation of the nursing process12.

In the Location axis, the constant terms "Asylum," "Hospital," and "Home" represent the primary settings where nurses encounter VAOA. It can be inferred that the home is the initial setting where nurses can identify cases of violence early and potentially break the cycle. The hospital offers resources that enable professionals to provide more complex care resulting from violence. The long-term care institutions (asylum) ILPIs are crucial for recognizing the clinical and functional vulnerabilities of elderly individuals, which can predispose them to violence perpetrated by health professionals in these settings.

Among the constant terms in the Client axis, "Caregiver," "Family," and "Elder" are highlighted. Although the elderly are the primary focus of nursing care in this study, it is also important that the family and caregiver are integrated into the nurse’s scope of care, including accountability for actions and intentions in addressing violence within the family unit.

In the context of VAOA, the term "Hospitalization" from the Time axis represents one of the main consequences of violence in the literature, whether due to neglect or physical violence. The nursing team is responsible for reassessing the status of elderly individuals in hospital settings, strengthening their bond with these individuals and their families, and aiming to identify cases of violence early while activating available protection networks23.

In the non-constant terms of the Focus axis, "Family Abandonment" is a phenomenon of interest for nursing practice. A study conducted in Campinas - SP reported that between 2009 and 2019, abandonment was predominant in 33.13% of cases, primarily perpetrated by children1. Nurses working in Primary Care should identify such situations during home visits to plan timely interventions and ensure a protective network for the victims.

Other types of VAOA such as Self-Neglect, Neglect, Financial Abuse, Physical Violence, Psychological Violence, and Sexual Violence are listed as non-constant terms and represent priority targets for nursing care. The inclusion of these terms as potential nursing diagnoses enhances nurses' understanding of the forms of violence and the incidence of underreported cases, and may prompt municipal management to address the reality of violence, guiding these professionals to plan and deliver care aligned with the experiences of the issue.

Additionally, within the Focus axis, the terms "Chain of Custody" and "Understanding of Violence" are emphasized. The first term refers to procedures conducted by health professionals dealing with cases of sexual violence, characterized by the collection, recording, and storage of biological material. If performed correctly, the chain of custody ensures the preservation of evidence and assists in the forensic examination of the crime24. However, this practice presents a challenge for nurses due to the scarcity of forensic nursing practices in the national context and the need for ongoing education. Thus, in addition to the specific responsibilities and protocols inherent to nursing practice, the effective execution of a chain of custody enhances forensic practice, leading to improved victim care25.

Regarding the "Understanding of Violence," this term describes the victim's awareness of the phenomenon experienced. In cases of psychological violence, many older adults may not recognize that they are suffering from such abuse, either due to denial of mistreatment or a low level of educational attainment23. Consequently, health education during nursing consultations can be a potent strategy to help elderly individuals recognize that they are victims of violence and feel supported by the nurse to address the situation as effectively as possible.

In the Judgment axis, the terms "Threatened," "Intimidated," "Isolated," "Fragile," and "Vulnerable" align with the emotions resulting from the nuances of violence. Threats and intimidation reflect actions of psychological violence perpetrated against the older adult. Isolation is present in situations of abandonment, financial abuse, psychological abuse, neglect, and self-neglect. For example, during the Covid-19 pandemic, a review indicated that although social isolation was effective in reducing virus-related morbidity, it led to an increase in cases of violence. The restriction of older adults to health services and community networks intensified intrafamily interactions, which likely resulted in increased stress and violence against them26.

In the Action axis, some non-constant terms such as Instrumentalize, Intervene, Reassess, and Systematize are noteworthy. With the exception of the term "Instrumentalize," which could involve actions related to equipping the nursing team with appropriate practices for cases of VAOA, the other terms align with the nurse’s competencies within the nursing process. This method allows for systematic and deliberative adjustments to planning, enhancing the effectiveness of interventions.

Among the non-constant terms in the Means axis, Anamnesis and Instrument are crucial for screening VAOA. Anamnesis is essential as the initial step in the nursing process, helping the nurse accurately outline subsequent stages and ensuring the effective investigation of cases of violence. The term Instrument is represented in the literature with tools that facilitate the detection of risk and violence, including validated versions for the national context27.

Reporting and Mandatory Notification are non-constant terms in the Means axis. Although distinct, these instruments complement each other in the nurse’s role, enhancing the protection network for elderly victims of violence. Mandatory notification is required to document epidemiological situations, including violence. Health professionals must report suspected or confirmed cases to health authorities for appropriate interventions1. This reporting process also involves communicating with law enforcement to initiate criminal proceedings under the guidance of the Public Prosecutor’s Office.

Regarding the non-constant terms in the Location axis, Primary Care and Elderly Police Station are noteworthy. Primary Care is the preferred entry point for services within the Unified Health System (SUS). In the context of violence, registered professionals have the public health responsibility to identify, discuss cases with the team, intervene, and monitor elderly users in the territory, with the aim of breaking the cycle of violence28. The police station, in turn, is an intersectoral point of attention within the network of assistance for victims of violence, responsible for case registration and taking corrective measures against perpetrators of violence against the elderly29.

In the Client axis, non-constant terms such as Perpetrator, Spouse, Child, and Man highlight the profiles of those who commit violence. A study conducted in Espírito Santo found that 59.2% of perpetrators of violence against the elderly were male, with 56.1% being children and 23.5% being partners of the victims30. In addition to understanding the phenomenon of violence, it is essential for nurses to utilize epidemiological data, such as the aforementioned findings, in their routine care to grasp the reality of the profile VAOA and to develop effective measures.

This study faced a limitation due to the extended time required for validation, as communication with judges occurred solely through online tools.

However, the study underscores its contributions to nursing education by strengthening the ICNP^® framework, enhancing clinical reasoning tailored to the needs of clients under the care of students, and integrating the approach to older adults in situations of violence into geriatric health courses. The research highlights the emergence of new terms in the ICNP^® and the expansion of results related to the nursing process and specialized terminology. In assistance, there is potential to develop new diagnostic statements, outcomes, and nursing interventions to improve the care plans conducted by nursing teams for elderly individuals at all levels of complexity.

CONCLUSION

The development of a term bank for nursing practice with elderly people in situations of violence initially involved extracting 10,731 terms using the PorOnto tool. After normalization and standardization of the terms, 1,236 terms remained, which were then subjected to a validation process by experts. Out of these, 704 terms were validated, with 293 being consistent and 411 non-constant in the ICNP^® 2019/2020. The significant number of non-constant terms highlights the unique aspects of a terminology specifically designed for elderly individuals in situations of violence.

With the term bank, statements of nursing diagnoses/outcomes and interventions were developed, which will undergo content and clinical validations of diagnoses/outcomes and nursing interventions. In the future, it will be possible to structure a terminological subset of ICNP^® to expand the scope of forensic nursing, ensuring documentation and applicability of a nursing process with unified language across all levels of care.

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NOTES

• ORIGIN OF THE ARTICLE

  Extracted from the dissertation - Diagnoses, Outcomes, and Nursing Interventions for Elderly People in Situations of Violence, presented to the Graduate Program in Nursing at the Universidade Federal da Paraíba, in 2023.

• FUNDING INFORMATION

  This study was funded by the National Council for Scientific and Technological Development (CNPq), through the NCTIC - CNPq call 28/2018, under process number 424604-2018-3; and the productivity call 03/2020, process number PVG13127-2020.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Ethics Committee in Research of the Universidade Federal da Paraíba, opinion n.º3.709.600/2019, Certificate of Presentation for Ethical Appreciation 10179719.9.0000.5183.

• TRANSLATED BY

  Leonardo Parachú

Edited by

EDITORS

Associated Editors: Jaime Alonso Caravaca-Morera, Maria Lígia Bellaguarda.

Editor-in-chief: Elisiane Lorenzini.

Publication Dates

• Publication in this collection
  14 Oct 2024
• Date of issue
  2024

History

• Received
  27 Nov 2023
• Accepted
  12 July 2024