Execution capacity of instrumental activities of daily living in elderly : Ethnonursing

Objective: To analyze the health and nursing interventions proposed in community groups for the elderly. Methods: Qualitative study, of etnonursing type. The study included 35 aged subjects who were part of a university extension project. Data collection was based on the Observation-Participation-Reflection model, field diary and interviews. Data analysis followed four phases. Results: The workshops were contextualized as the needs of the elderly to carry out the activities of daily living. Autonomy and independence emerged as health predictors. The living group was referred to as promoter of active aging and healthy culture. Conclusion: Groups are spaces for possible problematization of demands of the elderly, regarding the implementation of the activities of daily living. Functional capacity, autonomy and independence were determining factors for the health and well -being of the elderly, and they should be the focus of nursing intervention.


INTRODUCTION
Due to the fact that aging is a multifactorial process, health promotion of the elderly, as well as their health actions, should be addressed in spite of the global functionality that is defined as the capacity of managing their own lives or even as taking care of themselves.Even in the presence of diseases, if subjects are capable of functioning by themselves, i.e. presenting autonomy and independence, they might be considered healthy 1 .
Thus, the view of elderly attention is extended to beyond the biological view and the disease focus by suggesting sociocultural approaches with impact on life style, on the promotion of an active and healthy aging, with emphasis on community groups for the elderly, which is a promising gerontological nursing workplace.
Functional capacity should guide the care for the elderly, which fundamentally includes the concepts of autonomy and independence.Autonomy might be understood as the individual capacity of decision and command on someone's decisions; on the other hand, independence should be understood as the capacity of doing something through someone's own means 1 .
The evaluation of functional capacity comprises two domains: the Basic Activities of Daily Living (BADL), self-care or personal care activities like feeding, bathing and dressing; and Instrumental Activities of Daily Living (IADL), which consist of mobility skills or activities for environment maintenance including more complex tasks that are mostly associated with subject's social participation, such as shopping, answering the phone, and using means of transportation 2 .
Therefore, in the community groups, there should be an adaptation to the execution contexts of these activities, especially the IADL, in order to include environment, people, elderly, and activity that will be conducted.These activities should be inserted as interventions in the elderly groups for health maintenance or promotion in a gerontological care context 2 .
Hence, the elderly community groups are proposed as a support intervention technology, understood as spaces to share livings, strategies for health education, besides as an interaction of the health work process technologies for care effectiveness 3 .In this way, the groups are spaces that are possible and capable of satisfying the demands showed by the elderly, because they privilege human beings, meetings, dialogues, and provide the elderly a voice.They also allow, through sensitive hearing, identifying the needs by contextualizing such activities in a care environment that promotes health, an active and healthy aging, and protagonism.
These activities aim at creatively promote health and operationalize the elderly; adopt healthy life styles and habits; and foment the insertion and strengthen the elderly social role 4 .They also permit the acquisition of new knowledge and skills to perform the IADL by both strengthening health self-perception and social insertion.Therefore, interventions that ensure maintenance and promotion of IADL capacity are important.
It is possible to work with workshops of theater, dance, languages, social and cognitive memories, citizenship, art therapy, group physical activities (like hydrogymnastics and stretching workshops), animal assisted therapy, daytrips and exhibitions in the community groups.Interventions directly and indirectly stimulate the autonomy and independence by stimulating their functional domains: cognition, humor, mobility, and communication 1 .
Hence, some activities might privilege one rather than the other domain, or even the functioning, in a global manner.Awareness of which domain is proposed in the activity prepared by the team might provide a therapeutic connotation that is as necessary as the performance of uncommon activities of the health and nursing areas, but which are also necessary for health maintenance in the group of independent elderly subjects.
Studies point out that better health conditions; interpersonal familiarity; performance of physical activities; improved quality of life and share joys, sadness and knowledge are objects to be achieved in the groups and are a motivation to seek them.This decreases direct and indirect costs, like hospitalizations, use of medications, incapacities and need of informal or formal caregivers 4,5 .
Gerontological nursing might be a creative option, since it uses elderly groups as spaces for actuation and creation of an environment that promotes health.In order to do so, it is essential knowing the client, because sociocultural practices can make the aged person closer to the professional, thus allowing actions based on individual experience 6 .In addition, it is possible through the environment changes and dialogues that identify the common demands of the group -it is an activity that has been developed in groups through the interlocution of knowledge and practices, but that it is still performed based on the subject's scope.
Thus, the Theory of Diversity and Universality of Cultural Care was chosen as the theoretical and methodological referential.According to this theory, the subject's worldview of care is influenced by some factors, such as the economical, social and educational ones.Then, nurses can offer appropriate care to their client's reality, i.e. congruent care.Beliefs, expressions and care patterns are considered the values of cultural care, which are properly known and used with sensitivity.Therefore, care becomes significant to the person receiving it 7 .
This study aimed at analyzing health and nursing interventions proposed in community groups for the elderly.

METHODS
This is qualitative study of ethnonursing type, which is defined as an ethnographic method of research that aims at systematically discovering, describing and analyzing the expressions of care, patterns and practices of people in their natural environment contexts 7 .
The setting was an extension project of a public university in the city of Niterói (Rio de Janeiro, Brazil), where group activities were developed as workshops with the elderly.This setting was common to the investigator, since he/she developed activities as Cognitive Memory Workshops, which became a facilitator for approximation and entrance in the field, but without forgetting the research objectives.

Execution capacity for activities of daily living
Santos GLA, Santana RF, Broca PV The adopted research method establishes two types of informers.Thus, 35 aged people chosen by convenience were the Key Informers 7 .The inclusion criteria were: participating for at least one year in the project activities in a regular basis and being available to attend in the day scheduled for the interview.The exclusion criteria were: being absent in two scheduled meetings; cancelling or not attending the activities of the extension project.
Seven professionals that worked in the extension project were the General Informers.The inclusion criteria were: complete undergraduation course; directly work in the extension project workshops or in their coordination; develop research activities; and work as administrative technicians in the project.Interns, subjects with an academic scholarship, those who work as a support in the project and those who did not attend two scheduled meetings were excluded.Result saturation, culminating in data repetition, was the criterion used in order to select the number of informers.
Collection of data was done based on the Observation-Participation-Reflection model (O-P-R) of observation, as well as on field diaries and interviews with the Key and General Informers.The four phases associated with the method were followed 7 for data collection procedures.
In phase I, the initial observation and recognition interview were conducted to recognize the communication patterns among the elderly, the routine reports of IADL execution and the cultural context of IADL execution.The interview enabled to choose the first Key Informers, as well as to extend and deepen knowledge about the study participants and settings.The interview was conducted in the extension project, lasted around 60 minutes, and was recorded and transcribed.
The first notes were written in the field diary by highlighting the aspects regarding the research and the notes of speeches, gestures, postures and scenes where the occurrences took place.Additional aspects were noted after material observation and reading.Certain distance was sought, which is a characteristic of the non-participant observation; alternatively, since the investigator was known in the group, he/she became involved in the conversations, however, when possible, he/she observed without so many interferences, thus favoring the observation and note in the field diary.
In phase II, we tried to identify and increase the amount of Key Informers and we conducted the deepen interview, which is a result of the recognition interview and the questionings from the first observations.The script was based on the theoretical referential and comprised factors like technology, religiosity, social and cultural relations and life styles; politics and laws; economy and education.These factors contribute to the worldview of subjects that is expressed by their values and beliefs.The observation was still continuous, but there was approximation and interaction with the elderly.Each interview lasted around 60 minutes and was conducted in a calm and private room, thus favoring an open and honest dialogue.
In phase III, the observations done in the dependencies of the extension project were enlarged, as well as there was a search for the places of IADL execution that had been mentioned by the elderly in the interviews, like shopping malls, bank institutions, supermarkets and collective transportation.There was an active participation in the observation spaces in this phase, since there were some research questions that needed deeper investigations, which is only possible through the dialogue with subjects.The period of observation totalized 58 hours of observation that were distributed into moments of observation in the previously mentioned settings.
For data confirmation and validation, a thematic meeting was scheduled with the elderly to discuss the findings.Multimedia resources were used by projecting pictures that symbolized the issue to be addressed, stimulating group dialogue.Important questions were also written by confronting data produced in this meeting with those from previous phases.Exhaustive readings of the produced material enabled the next phase of the analysis.Thirty elderly subjects from both genders took part in phase IV.The meeting lasted around 2 hours.
Data analysis was based on ethnonursing 7 .Each phase and their respective analysis actions can be seen in Figure 1. The

Characterization of the study subjects
The sociodemographic variables of 35 elderly participants comprised: 82.9% were female; 52.3% were aged between 70 and 79; 57.1% were retired; 31.3% had an income of up to two minimum wages; and 28.1% had an income of more than three minimum wages.With regard to schooling, 48.6% mentioned elementary school.As to birthplace, 59.4% of the elderly referred to Rio de Janeiro State and 75%, the city of Niterói as their current location.
With regard to health condition, non-transmissible chronic diseases stood out, since 52.6% mentioned blood hypertension, followed by dyslipidemia (18.4%).The cardiologist physician was mentioned as a reference for health monitoring by 55.5% of the elderly.Vision, with 82.4%, was the most indicated special needand all subjects in this percentage wore glasses.

Interventions for maintenance and promotion of capacity for Instrumental Activities of Daily Living: a health concept for the elderly
In elderly health, the act of maintaining a preserved functional capacity can be understood as being healthy.Thus, autonomy Execution capacity for activities of daily living Santos GLA, Santana RF, Broca PV and independence were health predictors, even in the presence of a chronic disease or multiple comorbidities, which is a common profile to the population of this study.

With all the diseases I have, I am very healthy. Because I do everything, I am independent; I do not need anyone to help me (…). (IC-28)
The self-assessment on how their health was, based on the elderly speech, was not simply associated with absence of diseases, but with the capacity of remaining active and performing their IADL.
Health influenced on the elderly perception about his/ her feeling of utility and social belonging.Being healthy, in the respondents' speech, meant freedom, autonomy, independence, self-governance and protagonism in life.

Health is essential. I do not need to take a bus to come to the project, because I come on foot; but to go to the bank, to stores and to the market, I need to take a bus. I sometimes go on foot from Ingá to Midtown, and I return by bus because I bring a purse. (IC-1) By being healthy, you will have energy to do all chores you need to do, right? To go shopping, to go to the supermarket, to go to the shopping mall, to window-shop, to go to the movies, to go to the beach […] And I am able to do all of these things because I am healthy. (IC-16)
However, the aging process brought some limitations, difficulties and challenges in the performance of daily activities.The organism biological reserves tended to be less effective to the presented demands, such as the purchase volume and the weight bore by the elderly, and gait, which could also be slower.
Then, adjustments in the execution of IADL were needed, but they did not consider approaching subjects regarding current subjects like the use of technologies, body knowledge and recent phase they had been living, or even the acquisition of communicative skills.

Execution capacity for activities of daily living
Santos GLA, Santana RF, Broca PV

Walking calls my attention, I walk a lot […] people pass by me, and they are soon distant. I have always walked quickly, I have always followed people on the sidewalk and now I have noticed that my steps are not very long, I am slower, but in general, I am physically fine. (IC-13)
One of the forms of adaptation to limitations and demands of the current life phase was attending group activities.In the project, the elderly acquired physical aptitude and training with functional and cognitive memory exercises.In addition, they accumulated personal, social and psychosocialspiritual resources that could be maximized by the variety of activities provided and attended by the elderly subjects.These activities varied from physical activities to those for the cognitive memory, language classes or discussion on elderly rights.
We retire and we cannot stand still, my husband died at 55 years old and I thought, I have to find something to do.So I came here to the project, this helps me at life in general, I do not like to stand still, I do not like to watch television.(IC-10) Go after your goals, do not stand still, for more than 10 years, I had not had the agility that I have today.I stopped working in 2002 and since then, I did not have the energy and disposal to work and when I came to the project, I stopped being bored.Now I feel more skilled to make things, before I only had one day, the rest was always tiresome.In the other year, I came twice a week, now I come every day, and I arrive happy, I arrive tired at home, but happy, I came, participated, met people and exercised.(IC-23)

Community groups as promotors of an active and healthy aging culture
Group participants were free to make critical notes about the activities, and they were also stimulated to express their opinions by fomenting an active participation and collective construction of the activities.
About 30 elderly subjects were gathered to discuss and assess the Theater Workshop activity regarding its functioning, and to give their opinions about the activity, discuss their last acting (a theater play) that did not happen due to weather conditions.In the day scheduled for the presentation, there was a heavy rain, so the play was cancelled.This kind of situation had already been agreed, when, due to bad weather condition or imminent rain threat, the activities would not take place.Several elderly subjects gave their opinions reinforcing the act of calling each other to confirm their presence, or not, and if the acting would happen, in such case.However, we observed that the participants of the Theater Workshop do not have a person of reference to take out all their doubts, besides the one in charge of the group.This is one among other facts mentioned that resulted, in that day, in a debate and proposal of commissions, where the elderly would work helping in managing the activities.(Note from the Field Diary.Niterói, November 27, 2013).
The participants still considered the group as a moment to care for their health.In the speech of informers, the project was translated into care and maintenance of health.
Health is everything: to work and to go to my activities in the Advanced Space.How do I take care of my health?By doing my activities, memory, psychology, yoga, fall prevention.(IC-14)

[...] By doing my activities here in the Space, by doing my exercises. (IC-31)
With regard to knowledge acquisition, the activities allowed access to themes of group interest, such as legal rights and instruments.

Even with the Elderly Statute, we do not notice much progress. Actually, our citizenship teacher […]
His workshop deals about themes that are important to us.We have been to Rio de Janeiro Chamber of City Councilors, we have watched two voting sessions, and when they were going to vote things in our favor, when they saw us there, they "went back on their word".(IC-32) The difficulties the elderly faced to perform IADL were, many times, indirectly expressed in the workshops and needed a sensitive and attentive hearing by the professionals.

[...] it becomes very hard, in an activity about prevention of falls in the middle of a pool, for him to report anything; things can happen isolatedly with the teacher in charge of the activity; so we have to tell about some difficulty, about falling on the street, routine difficulties, difficulties in facing the bad weather conditions. (IG-2)
Very little, because workshops are directed to theater activities.Of course, sometimes issues regarding buses come up, like the driver has difficulties to stop the bus, and now with biometry, it even gets more complicated.(IG-1)

DISCUSSION
The primary characteristic of interventions in groups for the elderly was the promotion of autonomy and independence.These are what allows them to access the group freely and spontaneously, without the help or support to perform their activities, i.e. the functional capacity is preserved.The aging process becomes healthy as soon as subjects adopt a healthy lifestyle and understand that aging does not private them of performing their activities 8 .

Execution capacity for activities of daily living
Santos GLA, Santana RF, Broca PV Health can be understood as a welfare condition that is culturally defined, valued and practiced 9 , i.e. it is influenced by the worldview that each elderly subject has and should be considered because it is translated into the life habits that are practiced and considered important for the living process of each elderly person.
Hence, chronic diseases are a reality in the elderly subject's health.Pathology findings, like hypertension and dyslipidemia, as well as visual alterations, were also found in another study with elderly subjects 10 .Interventions in this field should address healthy life habits and choices.Health education, for example, is a useful strategy and a possibility of intervention in the elderly subject's health.
The Theory of Diversity and Universality of Cultural Care allows nurses to extend their look to the elderly client's specificities.Then, nurses notice the factors that influence on the execution capacity of the elderly's IADL and those that motivate them to attend community groups, thus allowing to consider values, beliefs, and practices that are part of each subject's worldview 7 .
The act of considering the Theory of Diversity and Universality of Cultural Care means understanding what differences or variations are present, for example, in the life styles or even in the principles and values of each person 7 .By applying this concept to the context of groups, it is possible to know the specificities of the elderly subject so that nurses can identify which subjects and needs might be structured as workshops, seeking an intervention as close to the reality of each elderly person as possible.
However, another concept should be considered, the Universality of Cultural Care, i.e. the similarity or uniformity in meanings, models, values, life styles and symbols of care manifested in several cultures 7 , and in the context of this study, the community group of elderly.Care is a common and universal phenomenon, but the expressions of how this care happens are diverse, therefore the specificity of each one emerges in the community group for the elderly.
Nursing care in community groups for the elderly is based on developing skills to perform their daily functions, on being able to access messages from their cell phones, on consulting the price of a product in the supermarket or even on improving physical aptitude.The development of workshops that privilege and reproduce these daily scenes might be a useful strategy to the gerontologist nurse who wants to access universal and congruent care.Thus, health concepts and meanings should be considered because they portray the value attributed by such elderly subjects, with implications for life styles and health selfassessment 11 .
Another important factor to be considered in the preparation of interventions is the time of the elderly, the "slow pace" pointed out in the outcomes, which influences on how they will execute their activities.Elderly subjects must be aware that this time is different from that of other people, which influences on how they execute the activities in or outside the house or in the group -that is why we need to establish strategies.Nevertheless, even though normal aging might present a slow pace of the mental processes, this does not represent loss of the cognitive functions 10 .Furthermore, social isolation lived by elderly subjects might expose them to significant changes in humor.Depression also influences on the cognitive processes and slow pace is one of its characteristics 12 .
The elderly subjects indicated asking for help and information as strategies to get adapted to the aging process or even to the communication/interaction in the IADL execution.In order to do so, the "services/people" should be prepared: they should offer and support; use simple and short sentences; speak slowly; avoid interrupting the elderly person's speech; talk in front of the person; keep eye contact with the elderly; consider elderly time; and allow the elderly subjects to develop activities according to their personal characteristics.Thus, there will be a contribution to decrease the sounds in communication and interaction in the context of IADL execution 13,14 .
Therefore, attending group activities impacts on issues like health, self-esteem, bound and friendship formation.Groups are still an opportunity for socialization and development of physical activities 4 .In addition, health, autonomy, quality of life, functional independence and welfare are interconnected and there is an influence among them 15 .
Care with the elderly subject has some peculiarities and its characteristics are respecting the elderly subject and the aging process; focusing on the person and not on the disease; and considering the aged as an active participant in the issues of health-disease process 16 .
A recent study identified that participation in groups for the elderly is done through established friendship and changes, and it improves the self-esteem of its attendants.The experience allows exchanging experiences, interacting and strengthening support relationships.Friends are a social support and are more associated with emotional satisfaction, with making confidences and with sharing personal problems and joys 17 .
The participation between pairs and teachers, administrative technicians, besides students, characterizes the intergenerational living; therefore, there is an environment of active aging in the groups.
Thus, the view of gerontological nursing is based on a healthy aging focused on health promotion.Therefore, nursing care in groups should address several factors that achieve, through the workshops, a global functioning focused on functional capacity, which makes it a multidimensional process 17 .
A useful strategy could be awakening in the professionals the development of activities contextualized to the elderly's daily life, thus allowing the acquisition of skills and knowledge needed to execute the IADL.Groups were established as a space of acquisition, training and development of skills to perform the IADL.
The study limitations include the impossibility of interviewing professionals that care for elderly subjects in settings of external observation (shopping mall, supermarket, etc.), which could confront data of observations and interviews with elderly

Execution capacity for activities of daily living
Santos GLA, Santana RF, Broca PV subjects about their difficulties in performing IADL.Furthermore, the fact that the research problem was qualitatively addressed did not allow generalizations, but it highlights its contribution to the production of knowledge for nursing sciences, especially in Gerontology.
The applicability of this research results is in the proposal of activities in the form of workshops that provide the acquisition and improvement of skills, resulting in adaptation and resolution of demands in the practice life.

CONCLUSIONS
The community groups for the elderly are spaces for health promotion that work autonomy and independence, with a repercussion in functional capacity, as well as in the health self-perception of quality of life and welfare.Through the characteristics of activities, we can affirm the group promotes health, besides an environment of informal relational changes.The collective participation and development of workshops allow an active "participation", which is a characteristic of an active and healthy aging, with an effect on global functionality.By approaching the care on such perspective, we can see an elderly more adapted, conscious and inserted in the recent cultural and social contexts.
Gerontological nursing has a care focused on more than only the biological model, it seeks, through community groups, forms of creative interventions with significant effects on training and on the acquisition of skills, which enable an active aging.Thus, it collaborates to decrease costs with the population aging process and actions focused only on the disease and on the elderly's incapacity.

Figure 1 .
Figure 1.Diagram developed based on the Theory of Diversity and Universality of Cultural Care 7 including the phases of data analysis, according to ethnonursing.Aurora de Afonso Costa Nursing School, Universidade Federal Fluminense.Niterói, RJ, Brazil, 2015.
study development followed the standards of research ethics involving human beings according to Resolution number 466 from 2012, of the Brazilian National Health Council and obtained approval from the Research Ethics Committee of Universidade Federal Fluminense, under protocol number 246.268 from May 10, 2013.