Abstract

In Brazil, long-term care institutions for the elderly (ILPI) are the main long-term care providers for the elderly in situations of social vulnerability or fragile health. This study sought to analyze the perceptions of care managers and professionals who work in eight ILPI in different regions of Rio de Janeiro state regarding the institutionalization, difficulties of performing recommended care and how to improve these. A qualitative study was carried out that analyzed 38 semi-structured interviews: nine with care managers and 29 with care professionals. A thematic content analysis technique was used in trying to understand in the reports what the main challenges are to guarantee attentive and dignified care in these institutions. Violence has been found to be a major obstacle, which acts contrary to the care advocated. It manifests itself in different ways within the institutional reality: in the form of neglect and abandonment before institutionalization, but also within ILPI themselves. It appears in prejudices against the elderly: in the negative view of old age, in the infantilization and depersonalization of those that receive them, in the macro-political context, and by the absence or non-fulfillment of actions foreseen in public policies of attention to the elderly or in the lack of legislation that attends to their needs. Policies are necessary and need to be implemented. To this end, there should be more investment, especially in the training of professionals, so that long-term care is provided to the elderly in a dignified manner.

Keywords:
Violence; Elderly; Long-term Care; Public Policy

Introduction

Demographic transition can be understood as a process of which the result is population growth, with significant change in the population pyramid. In it, the proportion of children and young people tends to decrease, and the proportion of the elderly increases. Already well-known in developed countries, this phenomenon also occurs in countries that industrialized later. It can be explained by the reduction of infant mortality and by improvements in educational access, technological advances in health, progress in gender equality, promotion of family and birth rate planning, as well as public policies that have guaranteed benefits and income transfer for the most vulnerable members of the population (Souza; Melo, 2017SOUZA, A. C.; MELO, C. V. B. O mercado de trabalho brasileiro diante das perspectivas de envelhecimento da população. In: SOUZA, A. C. S. Brasil 2050: desafios de uma nação que envelhece. Brasília, DF: Centro de Estudos de Direito Econômico e Social, 2017. p. 19-43.). This transition is currently experienced in Brazil, in 14.3% of the population are elderly - that is, approximately 23.5 million elderly people (IBGE, 2015IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Pesquisa nacional por amostra de domicílios: síntese de indicadores 2015. Rio de Janeiro, 2015.).

In 2010, the number of elderly people in the state of Rio de Janeiro was 2,079,502 in a population of approximately 15,989,920 people. In the state capital, this number was approximately 940,000.¹1IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Censo demográfico 2010. Rio de Janeiro, 2010. Disponível em: <https://bit.ly/2FEsASe>. Acesso em: 28 mar. 2019.

This increase in the elderly population was accompanied by epidemiological changes in which chronic and non-transmissible pathologies, such as cardiovascular, cerebrovascular and neoplastic diseases, become more prevalent, which contributes to a condition of dependence or semi-dependence of the elderly. There is still a significant portion of the population who are socially vulnerable, a situation that aggravates or limits care for the elderly with functional disabilities (Chaimowicz, 2013CHAIMOWICZ, F. Saúde do idoso. 2. ed. Belo Horizonte: Núcleo de Educação em Saúde Coletiva, 2013.). When the elderly are limited in performance of their daily living activities, whether due to dependence in regard to some daily activities or lack of autonomy, long-term care services are usually necessary.

Long-term care can be defined as a wide range of services or assistance required for people who are in a situation of dependence (Matus-López, 2015aMATUS-LÓPEZ, M. Tendências e reformas nas políticas de atenção aos idosos com dependência. Cadernos de Saúde Pública, Rio de Janeiro, v. 31, n. 12, p. 2475-2481, 2015a.). Such care is recommended and established according to the social security system of each country. Countries such as Denmark, which adopt a social-democrat model, foresee measures such as regular preventive home visits. If necessary, the population can count on a state-contracted nursing service and, in some cases, domestic care services at home. There are other countries, such as Germany, in which the conservative model predominates, where care can be at home or in institutions. If the stay at home, the elderly person can choose to receive the benefit in cash or services (or both), and the amount stipulated depends on the degree of difficulty in performing daily living activities. There are also countries such as the United States, which is considered liberal, with little state intervention and a residual social assistance system that provides for nutritional programs, informal family caregiver initiatives, and preventative health care which is largely provided by the private sector (Pasinato; Kornis, 2010PASINATO, M. T. M.; KORNIS, G. E. M. A inserção dos cuidados de longa duração para idosos no âmbito dos sistemas de seguridade social: experiência internacional. In: CAMARANO, A. A. (Org.). Cuidados de longa duração para população idosa: um novo risco social a ser assumido? Rio de Janeiro: Instituto de Pesquisa Econômica Aplicada, 2010. p. 39-66.). It is worth emphasizing that such services and policies change over time according to the social, economic and political transformations of each country.

Latin America is marked by a plurality of public policies for long-term care: countries such as Chile, Argentina, Costa Rica and Uruguay have some kind of specialized home-based care system, while informal care is still predominant in Brazil and centered on institutionalization, with long-term care institutions for the elderly (ILPI) being the main long-term care option (Matus-López, 2015aMATUS-LÓPEZ, M. Tendências e reformas nas políticas de atenção aos idosos com dependência. Cadernos de Saúde Pública, Rio de Janeiro, v. 31, n. 12, p. 2475-2481, 2015a.).

The term ILPI was created by the Brazilian Society of Geriatrics and Gerontology (SBGG) to designate rest homes, geriatric clinics, nursing homes and shelters, amongst other denominations. These institutions appeared in Brazil in the late nineteenth century as the result of Christian charity and were intended to support the needy population. According to a census of the Institute of Applied Economic Research (IPEA), philanthropic ILPI are the ones that most offer (65.2%) long-term care for the elderly in Brazil. Private institutions are growing and appear second in the list at approximately 28.2%, and finally, public institutions appear with 5.2% (Camarano; Mello, 2010CAMARANO, A. A.; MELLO, J. L. Cuidados de longa duração no Brasil: o arcabouço legal e as ações governamentais. In: CAMARANO, A. A. (Org.). Cuidados de longa duração para população idosa: um novo risco social a ser assumido? Rio de Janeiro: Instituto de Pesquisa Econômica Aplicada, 2010. p. 68-92.).

In Rio de Janeiro, there are 285 ILPI, of which 147 are in Rio de Janeiro city and the other 138 in the Baixada Fluminense and the countryside of the state. Only one of them is public, being maintained by the Federal Government (Mangas et al., 2016MANGAS, R. M. N. et al. Caracterização das instituições de longa permanência no estado do Rio de Janeiro. In: MINAYO, M. C. S.; FIGUEIREDO, A. E. B.; SILVA, R. M. S. (Org.). Comportamento suicida de idosos. Fortaleza: Edições UFC, 2016. p. 343-365.).

Studies indicate that there is a growing demand for elderly people to enter these facilities, either on their own or their family’s initiative, or from public organs related to Justice, such as the Public Prosecutor (Camargos, 2014CAMARGOS, M. C. S. Instituições de longa permanência para idosos: um estudo sobre a necessidade de vagas. Revista Brasileira de Estudos de População, Rio de Janeiro, v. 31, n. 1, p. 211-217, 2014.; Pollo; Assis, 2008POLLO, S. H. L.; ASSIS, M. Instituições de longa permanência para idosos - Ilpis: desafios e alternativas no município do Rio de Janeiro. Revista Brasileira de Geriatria e Gerontologia, Rio de Janeiro, v. 11 n. 1, p. 29-43, 2008.). These ILPI are constantly associated with the total institutions described by Goffman (2010GOFFMAN, E. Manicômios, prisões e conventos. 8. ed. São Paulo: Perspectiva, 2010.), since the elderly often move away from the “outside world” and the institution itself manages the daily life of the residents.

The ILPI, according to Ordinance No. 73/2001 of the Ministry of Social Security and Social Assistance (MPAS) and the Secretary of State for Social Assistance (SEAS), are intended for the care of dependent and independent elderly people for daily living activities and must offer care that meets standards of dignity, preserving the autonomy, independence and family and community life of the users. Such institutions should develop socio-family work and activities to strengthen and restore family and community ties (Brasil, 2001a).

However, care in ILPI has often been marked by ill-treatment and neglect, which comes to light when extreme cases of violence against inmates, opportunistically exploited by the media, come to light.

In 2001, there was a national human rights caravan with the objective of getting to know the reality of asylums, shelters and institutions destined to shelter elderly people in Brazil and concluded that segregation and abandonment prevail in them. Many of these institutions presented precarious conditions to care for and provide decent and humane services. However, a number of laws and public policies have since been approved, such as the Statute of the Elderly and national typologies of social assistance services that provide regulations for the standard functioning of ILPI (Lima, 2011LIMA, C. R. V. Políticas públicas para idosos: a realidade das instituições de longa permanência no Distrito Federal. 2011. Monografia (Especialização em Legislativo e Políticas Públicas) - Centro de Formação, Treinamento e Aperfeiçoamento da Câmara dos Deputados, Brasília, DF, 2011.).

Taking into account the demographic, epidemiological, political and also demand changes for these services, we question the perceptions of ILPI managers and professionals about institutionalization, which is the main objective of this article.

Methodology

It is a qualitative study that aimed to analyze the perceptions of ILPI managers and professionals in Rio de Janeiro state on institutionalization, the difficulties in guaranteeing recommended care and the strategies necessary to overcome such difficulties.

Data from the study “Study on the ideations and suicide attempts of elderly people residing in long-term care institutions for the elderly in Rio de Janeiro” (Mangas et al., 2016MANGAS, R. M. N. et al. Caracterização das instituições de longa permanência no estado do Rio de Janeiro. In: MINAYO, M. C. S.; FIGUEIREDO, A. E. B.; SILVA, R. M. S. (Org.). Comportamento suicida de idosos. Fortaleza: Edições UFC, 2016. p. 343-365.) were analyzed, whose objective was to study the perceptions of ILPI workers regarding the ideations and suicide attempts of institutionalized elderly individuals. After the completion of this research, there was a vast and rich material still to be analyzed about the care provided in these institutions and the possible perpetration of violence within them. Thus, the data collected in the study just described were used in the current study.

Qualitative studies of secondary data can be valuable because they can provide new perspectives and aggregate elements that have not been analyzed before - although they can sometimes bring limitations to the deepening of the new thematic approach, since the initial objectives may not have investigated the new object of study in depth (Ritchie; Lewis, 2003RITCHIE, J.; LEWIS, J. Qualitative research practice: a guide for social science students and researchers. 2. ed. London: Sage, 2003.).

Thus, the new project, entitled “Violence in Care in the scope of Long-Term Care Institutions for the Elderly in Rio de Janeiro state”, used material collected in nine ILPI located in different regions of Rio de Janeiro: two institutions in the capital, four in cities of the Baixada Fluminense, two in the mountains region of Rio de Janeiro and one in the north of the state. These organizations are of varied legal status: four private, three philanthropic, one mixed (philanthropic and private) and one public.

The interviews, which were semistructured and individual, were carried out by trained researchers and applied to managers and professionals in each of the ILPI researched. The selection of the care managers was intentional and that of the care professionals for convenience. It was sought to contemplate care professionals of superior and technical levels. The interviews were recorded and later transcribed. They lasted from 40 to 60 minutes; some interviewees were brief in their considerations and others more verbose. All those who agreed to participate in the study signed a Term of Free and Informed Consent and understood the proposal of the study.

According to Figueiredo, Minayo and Mangas (2016FIGUEIREDO, A. E. B.; MINAYO, M. C. S.; MANGAS, R. M. N. Cuidar de si e cuidar do outro: a percepção dos profissionais e gestores das instituições de longa permanência. In: MINAYO, M. C. S.; FIGUEIREDO, A. E. B.; SILVA, R. M. S. (Org.). Comportamento suicida de idosos. Fortaleza: Edições UFC, 2016. p. 415-437.), although the research focused on suicide ideations and attempts, participants were able to speak freely about their professional experiences with the institutionalized elderly and related themes, such as public policies for the elderly, of care and proposals on how to qualify care in these institutions.

In this article, 38 interviews were analyzed: nine of them with care managers and 29 with care professionals, of which 14 were upper level (three social workers, three psychologists, three nurses, two nutritionists, a physiotherapist, a speech therapist and a pedagogue) and the other 15 were mid-level (eight nursing technicians, three elderly caregivers, three recreational assistants and one administrative technician).

Content analysis was used (Bardin, 2011BARDIN, L. Análise de conteúdo. São Paulo: Edições 70, 2011., p.37), which comprises of “a set of communication analysis techniques” consisting of three poles: (1) pre-analysis; (2) material exploration; and (3) treatment, inference and interpretation of results. For this research, the thematic analysis technique was used to interpret the data. Thus, the speeches were read profoundly and then we tried to organize and classify the speeches in three thematic categories, based on their similarities: (1) violence in the scope of the institutionalization of the elderly; (2) institutionalization, a violent act to break the violence of lack of care; (3) challenges to ensure the provision of recommended care.

Among all the constituted categories, that which refers to the origin of the institutionalization of the elderly individual was previously listed for analysis, as well as the comparison of this institutionalization according to the legal status of the ILPI. In the other analysis categories, the comparison in relation to legal status remained, as well as the individual’s role in the workplace (whether he was a professional or a manager).

Excerpts from interviews were used to exemplify some analyses, and the identification of participants was kept confidential (using fictitious names), indicating only their role in the institution (manager or professional), without naming the institution studied.

The new project was submitted to the Research Ethics Committee (CEP) of the National School of Public Health, located at the Oswaldo Cruz Foundation, with the consent of the coordinator of the original research, and was approved under opinion No. 2,111,969.

Results and Discussion

Some aspects regarding the interviewees and institutions researched

The care managers and professionals interviewed in the different ILPI had different trajectories of training and work experience with elderly people in this type of institution. The ILPI themselves also differed according to their legal status and geographical location in Rio de Janeiro state. Although there is a predominance of philanthropic ILPI in Brazil (which also occurs in this study), research indicates a significant growth in private institutions in recent years (Camarano; Barbosa, 2016CAMARANO, A. A.; BARBOSA, P. Instituições de longa permanência para idosos no Brasil: do que está se falando? In: ALCANTARA, A. O.; CAMARANO, A. A.; GLACOMIN, K. C. Política nacional do idoso: velhas e novas questões. Rio de Janeiro: Instituto de Pesquisa Econômica Aplicada, 2016. p. 479-514.).

The care managers have varied training and different experiences in charge of an institution. Among them were social workers, physiotherapists, a historian and an administrator. Two did not report their training, one of whom was elected to the position by the maintenance association and declared himself to have little experience with the elderly public; the other manager who also did not inform was already a volunteer in the institution and made it clear that she knew the dynamics of the place well.

Among these managers, three had been in care management for a year, two had five to ten years of work experience in the role, one declared that they had been managing ILPI for 16 years, and two said that they had been in charge of coordination for 30 years. There was one care manager who did not report how long he had held the position.

Among the 29 care professionals interviewed (excluding the nine care managers), 15 had completed high school or technical education, of which eight were nursing technicians. In relation to the 14 workers that had completed higher education, three nurses, three psychologists, three social workers, two nutritionists, a physiotherapist, a speech therapist and a pedagogue were heard. The majority (26) were female. The Basic Operational Norms for Human Resources (NOBRH) of the Unified Social Assistance System (SUAS) and the types of social assistance services (Resolution No. 109/2009) in which the ILPI are included, provide for the obligation of the use of social workers and psychologists in the professional context of these institutions, which may explain why many institutions have these professional categories in their team to the detriment of others (Brasil, 2006b, 2009).

Research conducted by Guths et al. (2017GUTHS, J. F. S. et al. Perfil sociodemográfico, aspectos familiares, percepções de saúde, capacidade funcional e depressão em idosos institucionalizados no litoral norte do Rio Grande do Sul, Brasil. Revista Brasileira de Geriatria e Gerontologia, Rio de Janeiro, v. 20, n. 2, p. 175-185, 2017.) found that none of the 11 ILPI surveyed on the northern coast of Rio Grande do Sul state had a directly-employed upper-level health professional. They were ceded by the city hall or volunteers, or even attended the elderly in the ILPI privately. This reality differs from that observed in this study, since the health professionals of eight of the nine institutions surveyed were hired by them, although some of the philanthropic ones had several volunteers and casual workers assigned by the municipality.

It was also sought to discover how long these people had worked in the elderly care institutions of Rio de Janeiro: four had been in them for less than a year, 12 had one to five years of work, five were there for five years and one month to ten years, and five were in those institutions for more than 10 years. Three people did not provide this information.

Violence within the scope of the institutionalization of the elderly

The analysis of the interviews of the care managers and other ILPI workers showed some themes that were widely discussed by all, albeit from different angles. In reporting their perceptions about the difficulties of providing care for the elderly as advocated by policies and laws, many of them emphasized that family abandonment, lack of professional qualification and institutionalization may be challenging and even aggravating the health problems of this population. Such situations are named by some of them as violent.

It is noted that violence can be present in institutions in a variety of ways, even if they are not explicit or cannot always be classified according to their nature, as is widely described in research specifically directed towards the elderly: physical, financial, psychological, verbal, sexual and self-inflicted violence and neglect (Rocha, 2017ROCHA, C. Violência contra idosos. In: SOUZA, A. C. S. Brasil 2050: desafios de uma nação que envelhece. Brasília, DF: Centro de Estudos de Direito Econômico e Social, 2017. p. 81-102.). Violence can be understood as the use of means or forms “of the annihilation of others, or of their direct or indirect coercion, causing them physical, mental and moral damages” (Rocha, 2017ROCHA, C. Violência contra idosos. In: SOUZA, A. C. S. Brasil 2050: desafios de uma nação que envelhece. Brasília, DF: Centro de Estudos de Direito Econômico e Social, 2017. p. 81-102., 84). Interpersonal, in groups, in a class and in specific genres or to be objectified in institutions.

Both ILPI managers and professionals perceive violence in entities in three thematic categories: (1) violence before institutionalization - this is one of the greatest causes for the sheltering of the elderly; (2) institutionalization as an act of violence, since institutionalizing the elderly is already a perpetration of violence; and (3) absence or limitation of public policies and lack of State initiatives, together with a lack of effective implementation of existing legislation. Some of these categories were more emphatically discussed by one or another respondent group. One should remember that the plurality of educational backgrounds and legal characters of ILPI interfere in the reality of work and in the interviewees’ point of view in regard to this.

Violence that leads to institutionalization can manifest itself in different ways. One of them, more reported by care managers, is a breach of rights. This refers particularly to the elderly in situations of domestic violence or vulnerability (street population, people with dementia or mental disorder, individuals without relatives etc.). These cases are mediated by the Public Prosecutor, which directs them to these institutions. This situation was expressed by a public ILPI manager: I receive, as a priority, 99% of the elderly who come here; they come by a warrant, from a judicial subpoena, they come by court order. Cases of homelessness, neglect, ill-treatment (Amélia, care manager).

This reality is consistent with the study by Pollo and Assis (2008POLLO, S. H. L.; ASSIS, M. Instituições de longa permanência para idosos - Ilpis: desafios e alternativas no município do Rio de Janeiro. Revista Brasileira de Geriatria e Gerontologia, Rio de Janeiro, v. 11 n. 1, p. 29-43, 2008.), which pointed to a growing demand for jobs at ILPI in Rio de Janeiro in 2007. At that time, this already indicated a need for expansion of these and other types institutions to assist the eldery as well as their family. The authors point out that the actions and projects carried out by the municipality, such as ‘Experienced Agent’, ‘The Elderly with Family’ and old age homes, are worthy in creating a partnership between families-society-State, besides promoting more dignified assistance to the elderly. Such actions are still in force in the municipality, despite fragilities arising from the current economic crisis in Brazil.

As expected, the relationship between the Public Prosecutor and private institutions is not established in the same way as with other types of ILPI. However, the issue of abandonment emerges as a similar feature between them.

The term “abandonment” was frequently cited in the interviews to portray various situations, such as cases of elderly people who are “left” by their families in a vulnerable situation and thus enter the institution through determination of the Public Prosecutor. It was also used to designate the fact that some relatives put the elderly in ILPI and no longer return to visit them or take them for a walk, as reported in the following speech:

Another conception indirectly associated with “abandonment” refers to the self-perception of some elderly that they are a “burden” for their family and choose to live in an ILPI by free will, although the interviewees point out that these are a minority. Such elderly people seek out the institution in the expectation of obtaining greater affective and health attention in these places.

Clos and Grossi (2016CLOS, M. B.; GROSSI, P. K. Desafios para o cuidado digno em instituições de longa permanência. Revista Bioética, Brasília, DF, v. 24, n. 2, p. 395-406, 2016.) describe that this desire to “not want to get in the way” or to be a nuisance is often a determining factor in an elderly person’s decision-making in regard to leaving home and going to an ILPI.

From the care manager’s point view - and above all, care professionals - the insertion of an elderly person in an ILPI also occurs due to the family’s lack of capacity or difficulty in providing the care they need, either for financial reasons, lack of time, absence of technical knowledge and handling care, or fatigue in caring for others, as the next speeches portray:

The Brazilian Federal Constitution, corroborated by other policies of attention to this population, such as Law No. 10,741/2003 (Statute of the Elderly), establishes that the responsibility of caring for the elderly is of the family, society and the State (Brazil, 1988, 2003). However, most of these families do not have the structural conditions to care for an elderly dependent or one that has no autonomy to manage their own lives (Guths et al., 2017GUTHS, J. F. S. et al. Perfil sociodemográfico, aspectos familiares, percepções de saúde, capacidade funcional e depressão em idosos institucionalizados no litoral norte do Rio Grande do Sul, Brasil. Revista Brasileira de Geriatria e Gerontologia, Rio de Janeiro, v. 20, n. 2, p. 175-185, 2017.). Relatives who care for semi-dependent or dependent elderly are more likely to suffer from physical and mental overload, financial problems, and sociability limitations (Rocha, 2017ROCHA, C. Violência contra idosos. In: SOUZA, A. C. S. Brasil 2050: desafios de uma nação que envelhece. Brasília, DF: Centro de Estudos de Direito Econômico e Social, 2017. p. 81-102.).

A study carried out in Uberaba (Minas Gerais State) with 729 elderly people found that violence was more prevalent amongst women aged 60 to 80 years, with a negative self-perception of health and dependent in carrying out basic daily living activities (Paiva; Tavares, 2015PAIVA, M. M.; TAVARES, D. M. S. Violência física e psicológica contra idosos: prevalência e fatores associados. Revista Brasileira de Enfermagem, Brasília, DF, v. 68, n. 6, p. 1035-1041, 2015.), which suggests that overload may be a risk factor for the perpetration of violence, as reported in the research (Lino et al., 2016LINO, V. T. S. et al. Prevalência de sobrecarga e respectivos fatores associados em cuidadores de idosos dependentes, em uma região pobre do Rio de Janeiro, Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 32, n. 6, 2016.).

Institutionalization: a violent act to break the violence of carelessness

The distribution of care provided for in Brazilian policies is declared by Giacomin (2014GIACOMIN, K. Contradições do estado brasileiro ante o envelhecimento do seu povo. Argumentum, Vitória, v. 6, n. 1, p. 22-33, 2014.) as a true privatist concept of old age, since it is conceived from a representation of the “ideal family” that can and should provide the elderly with highly complex care elderly that is beyond their abilities. According to this author, such conceptions, impregnated in policy, favor a perverse mechanism in which poor families must take care of elderly dependents without due state support. As discussed by Lino et al. (2016LINO, V. T. S. et al. Prevalência de sobrecarga e respectivos fatores associados em cuidadores de idosos dependentes, em uma região pobre do Rio de Janeiro, Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 32, n. 6, 2016.), this burden causes social and financial losses and damages the health of family caregivers, as well as being a risk factor for violence (mainly neglect and abandonment). When violence is identified, the Public Prosecutor’s Office is actioned, and then the elderly are removed from their home, because in many cases the family had no way of administering basic care (Giacomin, 2014GIACOMIN, K. Contradições do estado brasileiro ante o envelhecimento do seu povo. Argumentum, Vitória, v. 6, n. 1, p. 22-33, 2014.).

This perverse mechanism, therefore, dialogues and converges with the conception of institutionalization as an act of violence. Such a representation is mainly present in the managers’ discourse, regardless of the legal nature of the ILPI managed by them.

Three managers considered the rupture with the domestic environment or the depersonalization of the individual as violence, generated by institutionalization in an ILPI. In their view, “taking the elderly from their place” of coexistence and putting them in another is not a positive thing. From this, it can be deduced that in their perception ILPI are still far from being considered collective dwellings with minimum standards of dignity, as this extract demonstrates:

This same manager attributes the rupture with the environment itself as a violation of basic rights and, therefore, a violence. This discourse converges with what Goffman (2010GOFFMAN, E. Manicômios, prisões e conventos. 8. ed. São Paulo: Perspectiva, 2010.) describes as recurring among subjects entering a total institution: contact with the external world diminishes abruptly or ceases - and, as a consequence, their routine, their occupational roles, and their interpersonal relationships are disrupted.

In this extract, the care manager proposes a relationship between institutionalization and the loss of identity provided by these spaces, which depersonalizes the individual. A study carried out in the south of Brazil by Pavan, Meneghel and Junges (2008PAVAN, F. J.; MENEGHEL, S. N.; JUNGES, J. R. Mulheres idosas enfrentando a institucionalização. Cadernos de Saúde Pública, Rio de Janeiro, v. 24, n. 9, p. 2187-2190, 2008.), whose objective was to understand the effects of institutionalization on the life of the elderly, inferred that they often suffer the repercussions of symbolic violence due to the remoteness of their living environment and the breakup of family and social relationships built up throughout life. According to these authors, in the institutional context the discourse of the community asylum as a home is reproduced through the discipline. For them, in the institutional context the discourse of community asylum as a home is reproduced throughout the discipline. In this logic, the infantilization of the elderly prevails, whose speech is not taken into account.

In the interviews, this kind of “listening denial” of old people’s speech was even mentioned. However, it is perceived that even when they are heard, some professionals and managers think of old age in a derogatory way, as a phase of only losses, as per the following extracts:

The stereotypes present in the discourses of old age as a synonym of disease, loss, regression, human decay or a problem go against the way in which public policies and scholars portray this population, who can also be autonomous, independent and protagonists in the quest for their rights (Brasil, 2003; Minayo, 2014MINAYO, M. C. S. Manual de enfrentamento à violência contra a pessoa idosa: é possível prevenir, é necessário superar. Brasília: Secretaria de Direitos Humanos da Presidência da República, 2014.). However, it is necessary to ask the question: how to stimulate functional capacity and autonomy to manage one’s own life if those who care, although unconsciously, reinforce prejudices contrary to this? A study by Charpentier and Soulières (2013CHARPENTIER, M.; SOULIÈRES, M. Elder abuse and neglect in institutional settings: the resident’s perspective. Journal of Elder Abuse & Neglect, Abingdon, v. 25, n. 4, p. 339-354, 2013.) pointed out that infantilization and disrespectful comments are not really perceived as abuses by the elderly and care professionals themselves. According to the Handbook on coping with violence against the elderly, such judgements potentialize violence against this population (Minayo, 2014MINAYO, M. C. S. Manual de enfrentamento à violência contra a pessoa idosa: é possível prevenir, é necessário superar. Brasília: Secretaria de Direitos Humanos da Presidência da República, 2014.).

Challenges to guarantee recommended care

Training, courses and awareness in gerontology were mentioned by interviewees as actions that could break with and overcome this negative view towards the old, which is still very socially rooted.

This was one of the most mentioned topics as one of the challenges for promoting better care for the elderly in ILPI. Some terms, such as “training”, “worker preparation”, “specific courses”, “understanding” and “respect for the elderly”, are emphasized in the following extracts:

This discourse highlights the need for institutions to provide the means or tools for professionals to carry out dignified and excellent work. The lack of decent work conditions can reveal an institutional violence that affects both workers and the elderly, since the precariousness of the service provided can contribute to the occurrence of conflicts and violence between the elderly, between care professionals (Banerjee et al., 2012BANERJEE, A. et al. Structural violence in long-term, residential care for older people: comparing Canada and Scandinavia. Social Science & Medicine, Oxford, v. 74, n. 3, p. 390-398, 2012.), and from care professionals to the elderly. The following report reinforces the idea that the demand for adequate training for care professionals is greater than that of opening new ILPI: The view that I have of long-term care institutions today is a complete lack of preparation regarding service provision. Today, service provision for the eldery is very amateur (Frederico, care manager).

The “amateurism” present in the previous extract diverges from what is expected of the care advocated for ILPI. It is understood that “taking care” is an action that requires values, knowledge, and attitudes that can promote the potential of people for the maintenance or promotion of the human condition in the process of living and dying (Piexak et al., 2012Piexak, D. R. et al. Percepção de profissionais de saúde em relação ao cuidado a pessoas idosas institucionalizadas. Revista Brasileira de Geriatria e Gerontologia, Rio de Janeiro, v. 15, n. 2, p. 201-208, 2012.). This “care”, which can be qualified through training and awareness, is provided for in the National Policy for the Reduction of Morbidity and Mortality by Accidents and Violence and in the National Health Policy for the Elderly (Brazil, 2001b, 2006a). It is understood that this is a fundamental premise in the prevention of negligence and prejudiced attitudes from professionals, with institutionalized elderly being the most vulnerable group from a social and health point of view. The reality portrayed by care professionals regarding lack of preparation is described in an integrative review about the care and management demands of ILPI (Roquete; Batista; Arantes, 2017ROQUETE, F. F.; BATISTA, C. C. R. F.; ARANTES, R. C. Demandas assistenciais e gerenciais das instituições de longa permanência para idosos: uma revisão integrativa (2004-2014). Revista Brasileira de Geriatria e Gerontologia, Rio de Janeiro, v. 20, n. 2, p. 288-301, 2017.).

In addition, the aforementioned amateurism can be reflected in the difficulty that ILPI encounter in following what public policies that regulate these institutions advocate. According to many care managers and care workers, government at the municipal, state or federal level, also does not fulfill its role either in the constitution of programs for the elderly, in the creation of more ILPI, in the provision of more training courses in universities, greater supervision of ILPI or investments in modalities that can guarantee care at home, and providing alternatives so that institutions that do not meet all the requirements can improve.

The rhetorical and impractical character of Brazilian public policies, brought forward in this discourse, converges with what Giacomin and Couto (2013GIACOMIN, K. C.; COUTO, E. C. O caráter simbólico dos direitos referentes à velhice na Constituição Federal e no Estatuto do Idoso. Kairós Gerontologia, São Paulo, v. 16, n. 3, p. 141-160, 2013.) describe as symbolic legislations. The symbolic character of the law is instituted in the formulation of regulations without measures being taken to put them into effect. This mechanism perpetuated by the State, to reaffirm legislation in another, maintaining the family as the main caretaker without fulfilling its part of the measures provided for in those same policies, could be read as institutional violence. It is caused by governmental neglect in relation to policies - which are often discontinuous and poorly planned, and formulated only to meet the pressures of certain organized groups. It is important that civil society and all actors involved in aging and long-term care are present on the agenda of public policies, with due attention and effectiveness, so that the elderly are able to have their basic rights guaranteed.

Conclusion

The challenges of overcoming all forms of violence that occur in ILPI and improving care in these institutions can materialize both in concrete actions by professionals who are better trained in terms of knowledge and practices, such as in the political arena. The guiding theme of the analysis carried out - the violence perpetrated both before institutionalization and in ILPI - was a major problem, pointed out by the interviewees as impeding the guarantee of quality care for the elderly.

The analysis on the perceptions of ILPI care managers and professionals showed that neglect and abandonment are the other side of care within these institutions, even though they also occur in the domestic environment and in family relationships before institutionalization. These actors also understand how violent the State’s mismanagement is in the face of an aging population, violence characterized by the absence of effective policies for the care of the elderly in the country, but mainly in Rio de Janeiro.

On the other hand, they redeemed the possibilities and perspectives of a more dignified attention to elderly people assisted in these apparatus, indicating ways of training the professionals that attend them in these institutions and also the expansion and consolidation of effective and efficient public policies.

Although managers and professionals of ILPI with distinct legal characters have specific perceptions and demands regarding institutionalization, team building or their relationship with the Public Prosecutor, they also show similarities in the perceptions that institutionalization by itself can be a violence , that public policies have a rhetorical and impractical aspect, and that there is a need to support families in the difficult task of caring for elderly with chronic or degenerative diseases, such as Alzheimer’s, even without the minimal conditions.

This article shows that the analysis of the data collected in another research project was extremely useful for this one, which sought to shed light on some issues that always come to the fore when it comes to old-age care: in which conditions do they give themselves up for institutionalization - and once institutionalized, what care do they receive in those places? And what are the difficulties faced in enforcing guidelines set forth in current policies and laws?

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