Nursing consultation for the elderly : instruments of communication and nursing roles according to Peplau Consulta de enfermería para la tercera edad : instrumentos de comunicación y los papeles de la enfermería según Peplau

Objective: The main objective of this study was to identify the tools of communication and roles developed by nurses in interaction with seniors, according to the Peplau's theory. Methods: This is a descriptive research with a quantitative approach, performed by the footage of nursing consultations between May and September 2011 in basic health units in João Pessoa PB. Results: It was proven that Nurses were using the instruments highlighted by Peplau, especially listening to other. Concerning the roles described by the theoretical model, the most identified were the roles of substitute and leader. Conclusion: The data reflect the formation of links between professionals and the community. However, we need to find an effective communication during nursing care, making it possible for the patient to conceptualize their problems and, based on the understanding of their health status, use appropriate interventions, seeking to quality of care.


INTRODUCTION
Communication is the process of transmitting and receiving information on the relationships that occur during different phases and situations in life.The quality of relations significantly influences thoughts and actions, as well as leads to the understanding of concepts, principles and skills that compose human existence 1 .
It is observed that it is by means of communication established in nurse/patient relationship that is possible to fully understand the patient, seeking to understand his worldview and his attitudes.Therefore, it is necessary to pursuit of knowledge about the subject to direct the use of communication in various situations of care.
Restricting to the elderly, it is known that professionals should use appropriate resources to the care of this audience, as well as perform actions according to the population profile, aiming thus to implement an effective assistance.This requires training for professionals who have a different point of view of the elderly, aiming not only to promote the longevity of the human being, but providing this population a healthy aging, with a service aimed at the maintenance and adaptation of their routine 2 .
According to the Ministry of Health, for 2050, it is expected that, in Brazil, there will be more elderly than children under 15 years old, a phenomenon never observed before.This increase in the number of elderly raises the need for health services organized with the purpose of supporting the demand mainly to procedures and consultations with various professionals, since it must ensure health care for the entire population, including the elderly 3 .
Regarding the assistance in health primary care the nursing consultation is highlighted.This is a modality of assistance needed, inserted in the context of primary care that allows a systematic and continuous monitoring of the user, favoring the link with the community, multidisciplinary work and interpersonal relationship of the professional with the client and family 2 .
The relevance to investigate the topic of communication is evident and health professionals, especially nurses, need to be prepared to deal with the elderly and perform a multidimensional assessment.This would view the various aspects that influence their well-being, with regard to the development of their autonomy, their capacity for social interaction, their level of independence to carry out daily activities, as well as their self-realization 4 .
One of the ways to develop the professional knowledge and skills in communication is deepening in nursing theories, since those would provide the nursing scientific character, for making rational and systematic practice, which promote the formation of a moral/ethical framework to guide actions, providing an organized structure to the knowledge that, initially, it was just intuitive 5 .
Among the theories of nursing, in this context, the geriatric interpersonal relationship of Hildegard E. Peplau is highlighted, covering nursing as an interpersonal process, consisting of four phases, and describing the different roles exercised by professionals during the implementation of assistance.In this theory, the focus is the interpersonal relationship between nurse and patient, whose purpose is to seek the answer to the need to help them, aiming at the identification and resolution of health problems.
The theory emphasizes that the nurse should use the tools of communication: listening clarification and acceptance, and that nursing has six key roles: strange, resource provider, teacher, substitute leader and advisor.These functions performed by nursing emphasize practices that the nurse must exercise when relating to people.This occurs according to the needs highlighted in interpersonal relationship established in the nursing care 6,7 .
Based on what has been exposed, the interest in deepening the knowledge about communication emerged, more specifically, the communication on nurses' interaction with elders, which occurs in the basic health units.In this sense, it is observed the relevance in conduct studies geared to this clients in order to deepen and disseminate knowledge targeted to this population, as well as, contributing to improving the quality of care to individuals with 60 years old or more, in the health sectors.Given the above, this research aimed to identify the instruments of communication and roles developed by the nurses in the interaction with the elderly, according to Peplau.

METHOD
It is a descriptive research with quantitative approach, focused on the interactions established between nurses and elderly, during the consultations held in basic health units located in the municipality of João Pessoa.
Basic health units of this municipality are territorially distributed in five Sanitary Districts, which cut the entire length of the city.In Sanitary District I, there are fifty units; in the District II there are forty; in the III, 52; in the IV, 22, and the District V has 18 units.These data result in 182 family health units, with a team of health each one.
For the realization of the study, the Sanitary District III was selected, because it constitutes the field of practical implementation of the activities of the University, with which this research is linked.
The inclusion criteria in the sample for nurses were: to be part of the basic care assistance; to be present at the time of collection and accept to participate by signing the consent term and the term of Granting of Images.For the users, the inclusion criteria were: to be part of the community assisted by the basic unit; to be less than 60 years old; to be waiting for a consultation of Hiperdia or spontaneous demand with the nurse, and, at the time of data collection, to accept to participate by signing the consent term.
The exclusion criteria for nurses were not being part of the staff of the health unit, not being agree to participate in Nursing consultation for the elderly Silva JPG, Costa KNFM, Silva GRF, Oliveira SHS, Almeida PC, Fernandes MGM the research, not being present at the time of data collection.For users, the exclusion criteria were: being less than 60 years old, not being agree to participate in the research, present any limitation that prevents communication and interaction with the nurse.
The contact with the nurses of the institution was made in advance, in order to invite them to participate in the study and to obtain the official accepted, through the signing of the consent terms and of granting of image and sound.Of 52 nurses from the District III, seventeen denied the participation; two were on leave, and enjoyed holidays in time of collection, so that only 32 met the inclusion criteria and participated in this study.Thirty-two elderly people who were assisted by these Nurses, also participated during the period of fieldwork.
The data collection of this study was carried out from May to September 2011, through footage of nursing consultations with elderly, enabling the registration and storage of data by image and sound.This method offers some advantages for the researchers: to review the material collected as many times as it takes and, also, to obtain a certain degree of accuracy, since it is possible to analyze everything that was collected, without losing the details of the registered material 8 .
The instrument used for the analysis of the footage was built based on the theory of interpersonal relationship of Peplau, containing questions directed at nurses, referring to the interactional process, verifying the implementation of the instruments of communication: a) listening; b) clarification; c) acceptance, and the performance of the six roles exercised by the nursing: a) strange; b) provider of resources; c) professor; d) leader; e) substitute; f) advisor.In view of the prerequisites and having gone through the process of validation of the content required by the study, the footage made with the nurse becomes legitimate to the analysis.For each item of the instrument, there were five possibilities for classification of nurses' interaction and users during the research: it does not apply at the time; bad; regular; good and excellent.The validation was made, subjecting the instrument to the evaluation of three experts in the field of communication.The number of specialists is justified to avoid dubious questions in the circumstance of a tie 9 .
For the analysis of the footage, three nurses were invited and trained by the researchers to be judges.The training of judges was conducted according to the following steps: a) project of research exposition and of the theory of Peplau interpersonal relationship; b) presentation of the instrument to subsidize the production observed in the footage; c) use of footage-tests for the instrument filling exercise.
The analysis was performed by filling up an instrument every minute, from observation of each consultation performed by nurses participating in the research.The data were processed in Statistical Package for Social Sciences (SPSS) 18.0; analyzed through descriptive statistics, through relative frequency tables and percentages, and validated by the Chi-square tests of reason of verisimilitude and Cronbach's alpha.
For the completion of the research, the ethical observances were considered, included in guidelines and regulatory norms for research involving human beings, Resolution 196/96 of the National Health Council, especially as regards the free and informed consent of participants, secrecy and confidentiality of the data.
All research participants signed an informed consent term, as well as the term of granting of image and sound, in two copies, guaranteeing them using the material and data collected in the research, exclusively for the intended purpose.The images were used only for data analysis relating to the research.
It is worth mentioning that the research project was transferred to the Research Ethics Committee of the Hospital Universitário Lauro Wanderley (HULW), having been approved in April 5, 2011, under Protocol Number 091/2011, being also requested authorization from the Director/responsible for the municipal basic units selected for the research.

RESULTS
There were 468 minutes of footage, which corresponded to an average of 14.6 minutes per consultation.Below, there are the tables that correspond to the characterization of the participants.
In table 1, there are data related to gender and age group of nurses participating in the study.In relation to age, 12 (15.62%)were between 20 and 39 years old; 18 (56.25%)between 40 and 59, and 2 (6.25%) between 60 and 68 years old.As regards the gender, 29 (90.25%) were female, and 3 (9.75%)male.
In table 2, the profile data of the elderly participants in the study.
Below, there are data regarding communication tools used by the nurses and the roles exercised by the nursing during the consultations held with elderly in basic health care (Table 3 and Table 4).
For the listening, there were 1,185 records where most of them (62.87%) were good.There was also the clarification, communication instrument classified as good at 47.21% of their 1,002 records, and 77.72%, of 974 times acceptance instrument.
Nursing consultation for the elderly Silva JPG, Costa KNFM, Silva GRF, Oliveira SHS, Almeida PC, Fernandes MGM  In table 4, the most identified role, during the research, was the substitute, carried out in 408 interactions, in which 69.12% were classified as good and 17.16% as excellent.The strange role was the less present, registering 159 times, and classified as good at 55, 35%, and excellent at 27.67%.It is worth mentioning that this role had the excellent topic with the greatest percentage of classification.
The role with higher percentage of classification as bad, compared to the others, was the professor (4.02%).The role of leader had the regular item with highest percentage of classification (16.67%), being the second most performed, which resulted in a total of 360 interactions and, also, was the second classification as good (66.39%).The roles provider of resources and advisor were mostly classified as good, corresponding, respectively, to 63.55% and 63.02%.

DISCUSSION
The profile of nurses inserted in the research still is a reflection of the historical events of the profession, commonly found in Brazil, involving the female gender.Although they have observed increase in the number of men, over the past 10 years 10 .In relation to the demand for health care by the elderly, according to the profile of the participants entered in the sample, there is still a predominance of females.
Considering the assumptions of the theory of interpersonal relationships, used for the analysis of this study, the instruments of communication highlighted were: listening, clarification and acceptance.It should be noted that, in all the communication instruments, there was high reliability between the judges nurses, according to Cronbach's alpha, above 0.7 (Table 3).
The realization of listening by the nurses participants, has been classified by judges as good and excellent in its majority (76.29%)However, it was possible to identify, as well, during analysis of the footage, times when the nurse has not achieved this communication instrument properly, due to the need to carry out technical and administrative procedures.In this way, listening was also classified as bad and regular, with percentages of 2.03%, and 21.69%, respectively.
By listening, the most present communication instrument in this study (Table 3), it was possible to notice that the elderly feel valued in their needs and realized that their message was received.Listening is considered a mental process that demands more energy, in order to evaluate the received content without interfering with their own thoughts, offering the opportunity to the Nursing consultation for the elderly Silva JPG, Costa KNFM, Silva GRF, Oliveira SHS, Almeida PC, Fernandes MGM user completes his exhibition, consisting of values that are close, but with valuable information for the professional 11 .
In this understanding, it was observed the emphasis given to this instrument of communication, which allows the user to express their perceptions, feeling valued in interpersonal relationship with the nurse.Through listening, it is possible to recognize the needs of others, understand their world and their reality within the context in which they live 12 .
On assistance to the elderly, in addition to the therapy focused on exams and procedures that act on physical aspects, the professional should consider emotional aspects such as affective deprivation that surround him.Thus, the importance of appreciating how to interact and communicate, especially with regard to listening, because the elderly have peculiarities and their need for emotional security is a reality 13 .
For the clarification, identified in many interactions (Table 3), it allowed explaining the information provided during the assistance, to broaden the understanding of the elderly.A technique that can be used by professionals to assist in this instrument is called as clarification, which aims at the use of comparisons and definition of terms to broaden the understanding of information 14 .
It was noted, in the course of the research, that the clarification was present in the consultations, mostly being classified (47.21%) as good by the judges.However, it was possible to detect, also, that some nurses did not use this instrument of communication effectively, which can greatly hinder the understanding of the elderly about their state of health and care that must be performed to their well-being.
Two factors, identified during the analysis, which may have hampered the effectiveness of clarification as an instrument of communication, were: the induction of responses, that is, the way the nurse asks the elderly interferes with the response, and the assumption of the understanding of the message, that is, to not verify that the elderly understand what was said 14 .
It was also highlighted, due to the aging process, that the elderly may have psychological and physical declines that interfere in the cognitive process and, when added to undue actions of professionals, compromise the ability of understanding.Thus, the need to use strategies to enhance communication with the clients, such as, use short sentences and objective; use appropriate language; ask if they understood well the explanation; not to interrupt their speech and repeating the information, when necessary 3,11 .
With regard to acceptance, communication instrument less present in this study (Table 3), it is defined as the ability of nurses to accommodate the patient without the use of pre-designed trials, during the establishment of the interpersonal relationship.The attitude of acceptance of the nurse on the patient is influenced by their worldview, by culture, religion and race, by educational background and expectations 6 .
The nurses participants showed to accept the elderly, not using previous insights about users to direct the interpersonal relationship in the consultation, being the highest percentage classified as good (77.72%).In this way, the elderly felt confident to interact with nurses, and professionals could act, offering elements for the care of their health.
For the effectuation of the hosting of the elderly person, the nurses should understand the specifics of this population, considering their life story, since, with the experiences, people become generally wiser, developing greater sense of dignity and prudence and expect to be recognized for that.The host strengthens the bond between people, values the individual health care, as well as provides a reflective action and ethical and solidarity-based development to listen and engage in dialogue, generating professional satisfaction and users 15 .
As regards the roles (Table 4) which may be exercised by the nursing, focused by Peplau in his theory, these occur according to the dynamics of interpersonal relationship, and the nurse takes one of these roles in seeking to meet the needs of the patient, exerting therapeutic posturing.With that, the professional skills are being targeted as the interaction develops during the consultation.
It should be noted that occurred high reliability of the answers of the judges nurses when evaluating the images on this aspect, shown by Cronbach alpha value (Table 4).
Concerning the role of the stranger, the nurse, when performing it, he develops the first contact with the user, without judging their behavior, respecting their distance needs and viewing the report as a person emotionally able.This role requires the nurse that he set aside any stereotypical image he has about the elderly and develop a therapeutic relationship free from prejudgments.In this way, the professional should explore all potential demonstrated by the user in order to use them in favor of the relationship established between nurses and elderly and treatment planned for the balance of their health.
In the consultations, the role of stranger, when performed by the nurses, was rated as good and excellent at 83.02% of them, mainly the classification in good (55.35%).It is highlighted that by comparing it with others, this role was the least registered, since most elderly already knew the nurses and were accompanied by the professionals of the unit.This is because the basic health care aims at continuity of care and to bond with the team that is, the effective guarantee of care over time, especially in assisting the elderly person.
In this way, it is up to the professional to prioritize a therapeutic relationship since the first contact with the elderly, once the first interaction is fundamental for the development of the other, because, if the elderly stay with a negative impression of the nurse, the next interactions may be compromised, affecting also their monitoring by the health team.
To perform the role of provider of resources, the professional must provide specific responses to assist the user in understanding the problem or new situation, fact identified during the research.The elderly sought the nurses, relying on their ability to provide resources for understanding their state of health.In the research, the behavior of the nurses, to perform this role, was evaluated by the judges as good, at 63.55% and as excellent in 22.41% of cases.
Nursing consultation for the elderly Silva JPG, Costa KNFM, Silva GRF, Oliveira SHS, Almeida PC, Fernandes MGM In the elderly care, when the professional assists user's requests, developing a feeling of confidence in the health service, and also going more to the unit, strengthening the link with the health service, involving the whole family in order to use the service, in addition to becomes socially end of the socio-political process.This reflects one of the pillars of the basic care, since the assistance is made continuously by the health team and search the efficaciousness of the problems identified in the community.
Studies show that the use of health services by the elderly, in basic care, depends on the resolution presented by professionals and that the health needs of this population are comprehensive, including home care, actions geared toward chronic diseases, interventions for psychological aspects, etc.It is understood, therefore, that the care of the elderly person must be based on a general assessment 2 .
As regards the role of professor, Peplau believes that the nurse, in exercising this function transmits information to the user, always advancing from their prior knowledge and thus helping the learning process about the aspects related to health, as promoting their active participation in their experiences.Thus, the theory defines the professor, as an educator, in which the focus of their activities is the user's learning.
Concerning this, the nurse, in the execution of their duties, performs mainly the function of educator.Health education seeks not only the construction of a health consciousness able to reverse the population health framework, but intensifying popular participation in health care 16 .
It became evident during consultations, that nurses helped the elderly in learning new behaviors concerning their health and that they played that role positively, 62.95% classified as being good and 20.54% as excellent.However, in comparison with the others, it was the highest percentage of bad (4.02%) showing that there are still gaps mean interaction with elderly.
The elderly person may present difficulties for learning new knowledge, since limitations arising from the aging may compromise its ability to assimilate or habits that he performs with regard to health are so ingrained that prevent change of manners.This reinforces the need to apply professional knowledge from the information that the elderly have, so he can assimilate and accept more easily new habits.
The role of leader occurs when the nurse is able to observe and to understand the situation that affects the patient, understand what happens and appreciate the development of interpersonal relationship, targeting goals.It should be noted that the nurse, by exercising leadership role, must be in a democratic process, in which professional and user be participating, even if nurses are leaders.This role was the second most played by research nurses, having the highest percentage classified as good (66.39%).
The leadership transcends formal positions, or positions because it is due to a spontaneous and informal tuning established between people.The fundamental in the process of leadership is the appreciation of other people's action, in this case, the elderly 17 .In exercising the leader role, the nurses motivated the autonomy of the elderly, encouraging them to develop health actions previously planned during the nursing consultation, in order to continue the treatment effectively.
The nurse must preserve the active participation of the elderly person in the relationship, considering their beliefs and desires and bringing him to the planning of assistance.Health professionals play an important role in maintaining the autonomy of these clients since they can stimulate the elderly to perform certain daily activities, considering, of course, the limit imposed by the aging process.Some strategies cooperate in the promotion, maintenance or maximization of autonomy and independence of the elderly population, such as allow and encourage the elderly to perform personal care tasks; to discover their strengths and thus increasing their chance of participation in assistance; to respect their personal space and territorial cohesion; to provide time for their speech and display of feelings and concerns 13 .
The role of substitute, according to Peplau, occurs when the nurse is viewed as someone close to the user and is located in the place of another significant person, since he associates the characteristics of nurses at other people, feeling, then, supported by the professional.
In this sense, it is reaffirmed the commitment of the nurse as caregiver, to value the relationship with the user, making significant and therapeutic interaction, which highlight the modification of nursing care in a more humane and welcoming practice 1 .
The role of substitute was the most played, since it is very common to occur the nurse's association with people that the elderly already have related or with someone who is representative for them.When performing it, the nurses had the good rating in 69.12%, and excellent in 17.16% of cases.In some consultations, the elderly have shown enough confidence in the nurses, associating them to the people closest to the point of reporting information deemed sensitive and showing their love through affectionate and accolades gestures.In this way, to play the role of substitute can contribute to strengthen the professional relationship with the elderly.
In relation to the role of advisor, it occurs when the professional offers nursing care to meet their needs, using technical skills.Among the interventions performed by nurses, to provide assistance to the elderly, there are in the research, guidelines on nutrition; recommendation for physical activity; instructions on the use of medicines; planning to return in the consultation; request of examinations; checking blood pressure and capillary blood glucose.The interactions in that role was identified in the study, 90.19% were rated positively, between good and excellent.
It is known, therefore, that the health assistance to the elderly population includes understanding basic human needs, as well as adaptations to changes that occur throughout life, which in Nursing consultation for the elderly Silva JPG, Costa KNFM, Silva GRF, Oliveira SHS, Almeida PC, Fernandes MGM turn are biological, psychological, social dimensions and thus, cultural health actions should not only focus on the pathology, but prioritize the promotion, maintenance and restoration of health.To respect the independence and encourage the participation of the elderly subject in the process of care, can also encourage qualified assistance 4 .
The nursing profession has a fundamental role in assisting in the context of basic care, since he uses tools to promote health and to seek new perspectives more humanized care with people, especially with the elderly, who often are not valued by society due to their stereotypes 18 .
In this sense, the nurse has to be prepared to interact with the elderly, and facilitate their access to health services, as well as guide them in order to develop their autonomy and self-care.To do this, they must establish a therapeutic relationship, using the instruments of communication and performing their different roles in the care of the elderly.
With respect to the limitations of the research, there are interferences in the interaction between nurse and elderly due to the use of camcorders, the limitation of the researchers in the use of footage equipment and restricted the time to organize and assemble the equipment.

CONCLUSION
This study allowed us to identify the roles played by the nurses and the communication instruments used for them in the interaction with the elderly from the analysis, based on the assumptions of the theory of Peplau nursing consultations, recorded, confirming the scope of the objective proposed by this research.
It was possible to observe that the judges, generally as good, ranked the communication between nurses and elderly, with regard to the instruments of communication and roles exercised by the nursing.However, they are still checked gaps, since the results are classified as regular and bad attitudes, which must be avoided in order to reach the excellence of interactions on nursing care to the elderly.
Thus, as the professionals seek to improve the quality of interactions, communication between nurses and elderly, in basic care, it becomes more efficient, making it possible to meet the needs of this population.Among the instruments featured in this investigation, nurses have identified the listening as the most widely used therapeutic action.
The roles performed by the nurse were exercised in accordance with the needs of the elderly, given the dynamics of interpersonal relationships.One of the functions that can be exercised by the nursing, the research participants assumed, most of the time, the substitute and leader role, followed by the provider of resource, advisor, professor and strange, respectively.
There were some difficulties related to the use of footage, requiring a larger preparation of researchers with regard to the use of equipment, but also agility for pre-assembly in the data collection environment in order to ensure the record.It is noteworthy that this method enabled the detailed observation of the phenomenon investigated, enriching it with pertinent information to the subject under study, in addition to enabling further research and/or use of archived images as educational material, considering all the bioethical principles.
In this way, the study about this issue contributed to the knowledge of the importance of communication in the context of care for the elderly, emerging from their perception of the need to inform to society and, above all, encouraging the training of health professionals in this area to the conscious use of communication skills, so that the professionals interact better with the elderly.It is highlighted therefore, the need of development of future research in the area, applying the assumptions of Peplau's theory in other scenarios of care, as well as the deepening of the context of communication with elderly people in basic health care.

Table 1 .
Profile of nurses participating in the research, 2012

Table 2 .
Profile of the elderly participants in the research, 2012

Table 3 .
Classification of communication according to the communication instruments used by the nurse: listening, Clarification and Acceptance.João Pessoa -PB, 2012 * p < 0.0001.

Table 4 .
Classification of communication according with the roles developed by the nurse.João Pessoa -PB, 2012 * p < 0.0001.