Conflicts among institutionalized elderly women : difficulties experienced by nursing professionals

Objective: To identify the interpersonal conflicts among institutionalized elderly women from the perspective of the nursing team and describe the strategies adopted by the nursing staff in conflict situations. Methods: Qualitative and descriptive study conducted from March to July of 2015 with 15 nursing professionals from a long stay institution in the southern region of Brazil. Data were collected through semi-structured interviews and submitted to Thematic Content Analysis. Results: Conflict situations were identified among the elderly women relative to appreciation of the other and disputes for personal objects and physical spaces. The strategies adopted by the nursing staff were divided into behaviors conducted by dialogue or based on authority and a punitive character. Conclusion: Understanding the dynamics and origins of different interpersonal conflicts among elderly women can enhance nursing staff's interventions with this population by reducing conflict in number and intensity.


INTRODUCTION
The aging process affects the constitution of the individual, both physical and psychological aspects, as the social and cultural.Thus, the existence of physical limitations or chronic degenerative diseases are some factors modulating this process. 1Living with family changes to the same extent that these modulators are present, resulting in challenges in the daily lives of the elderly and their families.Added to this scenario, the new settings of families, the permanence of women in the labor market and the financial difficulties may disrupt the maintenance of the elderly under the family's responsibility in the home environment. 2n view of this, grows the search for care for the elderly outside of the family context and Institutions of Long Permanence for Elders (ILPE) become an alternative to housing and assisting them.The ILPE are collective residences that admit people over 60 years, in situation of low income and/or lack of family, with difficulties in the performance of daily activities, that require long-term care, as well as those who are independent able to carry out their self-care.3 The ILPE have different structures, commonly characterized as "total institutions", closed social spaces, with rigid rules, that define and standardize the activities of its residents, inflicting loss of their identity.4 In these institutions, there is regulation of time and social relations with the outside world, 4 which interferes, and even prevent, the continuation of life habits and social conviviality, previously constituted.From the entry of the elderly in the institution, with these characteristics, it usually keeps only the memories of objects and people from early life to this new reality.5 The elderly, in addition to the required setting to the rules and routines of the new space, faces "a lot of strange people", which might lead them to isolating due to the perception of not belonging to that location.In this situation, they may experience feelings of fear, insecurity and loneliness in face of the reality which is presented.6 Living in ILPE drives, even unintentionally, the development of relationships of the elderly with professionals and with other residents of the institution.7,8 These relationships, which are not always reciprocal, can be established in an attempt to keep them being and doing as prior to institutionalization; so that time may pass faster; and the individual needs of the elderly be met.8 It is worth noting that ILPE shelter elderly people from different social, economic and cultural contexts, whose behavior differences can motivate aversion and rejection among residents.9 Thus, it is understood that this situation, coupled with the characteristics of ILPE, potentiates and triggers situations of interpersonal conflicts between them and with them against the health team.
The conflict occurs when there is a clash of interests and divergent ideas between people or groups, changing the relationships.Interpersonal conflicts consist of social interaction situations of confrontation, disagreement and frustration, which cause negative effects on people's lives. 10When a conflict is experienced between the person with a group or with another person, commonly the actions of one of the conflicting are understood as good and the others as bad. 11Conflicts can arise from the difference in values and vanities among people, teamwork and societies.Thus, they belong to the reality of human beings and are essential to the personal and social development.However, it is necessary to find ways to best address them to prevent their aggravation. 12he understanding of the relationship of the elderly to other residents and with the professionals who work at ILPE is part of nursing care.Thus, it emphasizes the importance of investigating the situations of interpersonal conflicts of institutionalized elderly, aimed at establishing coping strategies for these situations by the nursing staff.
On the above, the study based itself on the following research questions: How does the interpersonal conflicts among elderly women residing in an ILPE manifest?What are the strategies adopted by nursing staff in conflict situations?With the objectives of identifying interpersonal conflicts among institutionalized elderly women, from the perspective of the nursing team, and describe the strategies adopted by nursing staff in situations of conflict.

METHODS
This is a study of qualitative and descriptive approach, conducted in an ILPE, in the southern region of Brazil.The institution has philanthropic character, welcomes and supports the elderly women, with limitations of resources (human, material and financial).The place is divided into four wards, where 190 elderly reside.The nursing staff is composed of 38 professionals.Of these, eight are nurses -being seven responsible for the assistance and one for management, and 30 nursing technicians.
Participated in this study 15 nursing professionals who attended the following inclusion criteria: be a member of the nursing staff of ILPE; have been employed for at least three months and not be away from work during the period of data collection for health reasons, vacation or maternity leave.The temporal criterion of work for at least three months was established for understanding that, during this period, the participants would have the possibility to have experienced conflict situations at the ILPE.All members of the nursing staff were invited to participate in the research, whose participation occurred randomly, according to the availability to be interviewed at the time of data collection.
Data collection took place from March to July 2015, through semi-structured interview.This was composed by issues related to the characterization of respondents: training, expertise in the field of Gerontology, gender, age, service time and bond with other institutions.Also with guiding questions of the subject under study: Tell me what conflict situations you experienced or witnessed, since you work in this institution.Talk about the strategies you use to deal with these situations of conflict.
For the implementation of the interviews, the researcher invited professionals of the morning, afternoon and evening shifts.From the confirmation of the participants, were agreed more convenient times to the interviews.These presented an average duration of 25 minutes, were recorded with the authorization of the participants of the survey and transcribed in full.All participants were informed of the objectives of the study and signed the Terms of Consent (TC).Data collection was closed due to data saturation, determined by repetition of answers and satisfactory range of proposed objectives. 13he data were submitted to thematic content analysis of the operative proposal of Minayo, characterized by two operating moments.The first, corresponds to the fundamental resolutions of the research, outlined in the exploratory phase of the investigation.And the second named interpretative, which was marked by the encounter with empirical facts, which was divided into two stages: sorting and data classification. 13Data analysis was anchored to a multi-referential perspective.
The study was approved by the Ethics Committee in Research with Human Beings of a higher education institution under the Protocol No. 980.585, being carried out in accordance with the regulations of the Brazilian legislation.In order to preserve the anonymity of the participants and the elderly women, the speeches were identified with the acronyms NUR (Nurse) and NT (Nursing Technician), followed by Arabic numerals.

RESULTS AND DISCUSSION
In this study, 15 nursing professionals aged between 25 and 50 years were interviewed, among these, ten were nursing technicians and five, nurses.The working time in the institution ranges from four months to six years, in which eight professionals were less than a year in this institution.Of the total respondents, four professionals were employed by another institution, in addition to the ILPE studied, and four had specialization in the field of Gerontology.
From the analysis of empirical data resulting from the interviews, two thematic categories emerged: "Situations of conflict among elderly women in ILPE witnessed by nursing professionals" and "Strategies adopted by the nursing professionals in face of the interpersonal conflicts of institutionalized elderly women".

Situations of conflict among elderly women in ILPE witnessed by nursing professionals
Conflicts in the ILPE space may be related to different circumstances that present themselves in the institutional routine.Among the situations reported by nursing professionals which have aroused conflicts among the elderly women, it was found that some residents seek to include themselves in a chimarrão circle, already formed, but do not succeed, which creates dissension.

On the chimarrão circle, she chose who took chimarrão with the group, it happens a lot here (NUR 4).
The residents of ILPE cultivate the habit of taking the chimarrão every morning, this is a typical drink of the South of Brazil.For this activity, the elderly women remain seated in a circle, share the chimarrão and talk between them.The conflict situations arise when new residents want to insert in this circle, already formed, and are rejected by some or most of them.
Sharing a cultural habit, for many seniors, means friendship, dialogue and interaction of a family life, constituting a way of facing daily life in ILPE.So, this time contributes to ward off feelings of loneliness and abandonment, commonly experienced in the institution. 14Therefore, the attempt from part of the elderly women, especially those who recently entered, to insert themselves in groups to feel belonging to these, although often not be accepted.
In addition to the friends' groups, the elderly women form bonds of friendship in pairs, in which two old ladies keep themselves closer and seek in each other support, protection, companionship and trust.
They talk: "Jane Doe cannot walk with the other, she has to walk only with me".Sometimes, they adopt a grandma like its daughter.Are issues like this, one takes a shower just when the other does, just does exactly the things that the other does.If Jane Doe fought with the other, she will also fight (NUR 3).
In daily living, are formed close relations among the elderly pairs and they perform most activities of their routine together as, for example, feeding and cleaning themselves.The bond of friendship between them grow stronger and bonds of affection are built, which are seen by the professional as a mutual protection relationship, as mother and daughter.So, when one is offended, the other enters the conflict in order to defend her friend.
However, not all elderly residents at ILPE are able, to some degree, to provide care to another.Though, taking care of others constitutes an attitude of solidarity and fraternity, which helps in strengthening their self-esteem, since they realize they are able to assist.In the institution studied, it was often observed elderly women walking together, offering water and assisting the other in guiding the wheelchair.This is established as the elderly, as well as any human being, are relational individuals, endowed with attitudes of care, both in physical and psychological dimension, as social. 14nother factor pointed as generator of conflict, is related to the attention that professionals of the institution provided to some elderly and not the others, at certain times.

Some old ladies are jealous of others, for example, if I'm going to set the snacks and one of them helps me, the other is jealous of the one who helped (NT 7).
In such cases, the conflict arises when some of the elderly considers receiving less attention from professionals compared to the other, and dispute among them the care of the professionals.This can also be identified at the time that professionals ask for assistance to some elderly women to carry out the routine activities such as the distribution of meals.Such situations favor to the discontent of those who are not called to help, and may be a contributing factor to the generation of conflicts.In addition, the elderly who are not called to work tend to claim reparation for the situation, which they consider unfair.
Thus, in the speeches, it is identified the dispute for affection, by the elderly women, as a reason for the occurrence of conflict.As a result, it is important to integrate professionals from other areas of the health field, such as psychology, enlisting more resources to the resolution of conflicts.It is emphasized that interdisciplinarity is a prerogative of the National Health Policy for the Elderly Person, in order to qualify the attending to the needs of the elderly population. 15till, were identified situations of conflicts for possession of personal belongings of the elderly women.

They fight among them, many times because of personal objects of theirs, they are very attached to these objects. This material part, they are very affective. There is one old lady that goes crazy every time some makeup or earrings disappear (NUR 3).
Conflict of all kinds, they fight even for lipstick, ring and for the chimarrão too (NT 2).

Otherwise, getting the other's flip-flop, it becomes a squabble (NT 3).
The conflict begins when the elderly women perceive the absence of their personal items such as make-up, earrings, lipstick or flip-flops.Items such as these have sentimental and subjective values to them, for composing their personal identity.In such cases, the elderly women get angry, feel hurt and discuss with other residents to demand the return of their belongings.
Professionals associated these conflicts of attachment that elderly women have for their possessions.It is understood that, within the institution, these objects make possible to preserve the identity of the elderly, so if someone remove it from them, a conflict will be set up.The objects constitute a set of individual belongings with strong relation to self. 4 So, to allow the elderly to keep personal items enables them to preserve ties with their own life story, as well as providing a familiar and welcoming atmosphere. 16n the institution in which was conducted the research there are clothes that are identified with the names of the residents.However, there are parts that are of common use and their possession generates conflict among the old ladies.

With the clothes, there are wards where each one has their clothes marked with their names in each, and, sometimes, one picks up the clothes of another (NUR 1).
They are like children, and do children's things, even for a cloth.One says: "those clothes are mine, not hers", they come to us and complain (NT 6).
Like for the clothes: "Jane Doe is wearing my clothes".That is it, because Jane Doe took the coat of another, Jane Doe took the cap ( NT 7).
The conflicts also arise when the elderly women make use of another resident's clothes, believing to be hers or, perhaps, by the difficulty in identifying the owner of the dress by the label.Consequently, the confrontation for the dispute of the garments is established.This fact comes because there are pieces of clothing of common use among the elderly women, mistaking them in identifying their own clothes.To claim their clothes, the old ladies are infantilized by the professionals of the institution or suffer by the negligence of these, as can be noticed in the segment "even for a cloth".
As well as the objects, clothes are part of the identity of the elderly women.To provide collective clothing at ILPE, besides generating conflicts, is one way to unsettle the identity of residents.Thus, it is important the initiative, for example, through family or donations, to provide clothes that belong to themselves, in order to preserve the identity of the elderly women at the institutional level.Furthermore, it is important that these garments remain in their own living quarters, so that they have the possibility of choosing the clothes of their choices to make use in their day to day.
The primacy of the elderly women for some physical spaces of the institution in which they stay for long periods, constitutes a conflict situation too.
On the day I arrived, they had a fight because one was sitting in the place of the other.Many times one drinks the chimarrão in the morning, where at noon the other has lunch.They are always in a fight (NT 5).

One of the old ladies wants just herself to stay here in the small kitchen, when another one comes and she doesn't allow her to stay. She gets mad, she swears. (NT 9). They seem have children's behavior, kind of child who fights for food and for space (NT 2).
There are elderly women who take ownership of certain physical spaces of the ILPE: the place on the dining table, the kitchen and the chair in the living room.The situation of conflict sets in when these spaces, recognized by themselves as their own, are occupied by other ladies, which triggers the fight between them.
As in a private residence, the elderly women seek in the institution places that are most pleasing to them or where they can identify something of theirs and, thus, try to maintain their identity.This question should be observed, since the housing is constituted as a space of representation and stories of its residents, which reflects the way of being and living and which corresponds as an area of refuge and protection for the human being. 17rofessionals, apparently, appear resistant to understand the need of the elderly women in preserving their identity, either through objects, places or affections.It is identified the childish treatment towards the elderly, by the nursing professionals, and that this may be related to the difficulty they have in understanding the behaviors of the elderly population.
Also, in the institution are assisted elderly women from different cultures and races, which may also generate conflicts.
There are old ladies here that are very racist with the others assisted.There are black women here, with very dark skin and they end up being excluded.It is complicated, because they are elderly people and we will hardly be able to talk to them and convince them that this is wrong, because it is something they experienced their entire life (NUR 1).
There is a bit of prejudice in my view, some assisted are black and there are elderly women who bother with it and, sometimes, scold (NUR 2).
Conflicts are motivated by racist attitudes of some old ladies against black colored residents.Some residents despise black women, feel uncomfortable with them and exclude them from the group activities.These old ladies joined the ILPE with prejudices formed throughout life, very difficult to change in old age, but that need to be controlled by the professionals of the institution, in order to provide a respectful and harmonious relationship among the residents.They must seek ways to facilitate coexistence among the various residents and minimize the occurrence and magnitude of conflicts.
Offensive and discriminatory attitudes present in interpersonal relations at ILPE, are forms of psychological violence among older women.A study with nursing professionals identified that racial prejudice and conceptions acquired prior to institutionalization, were factors that have influenced the behaviors of elderly to practice violence against other residents. 18This confirms the need to confront situations of racism, discuss them and thus minimize the aggravation and the frequency of conflicts.
In this category, it was possible to identify conflicts situations among the elderly women.These include feelings of devaluation by its own residents or professionals and the competition for personal objects and physical spaces of the institution.Also was revealed certain ignorance on the part of professionals to understand the attempts of the elderly women to preserve their identity, when disqualifying their desires and demands.

Strategies adopted by the nursing professionals in face of the interpersonal conflicts of institutionalized elderly women
In ILPE conflicts can occur between its residents and between those and the workers.In this scenario, it is up to professionals, including the nursing, to intervene appropriately to minimize and/or resolve the conflicting situations.In ILPE, place of this study, the nursing staff seeks to resolve conflicts, by trying to change attitudes of the elderly women understood as motivators of the disagreements.Therefore, they make use of authoritarian actions, by changing their tone, as one of the strategies adopted to resolve the disorders.
I call their attention a lot.I talk as if I was talking to anyone else, you have to end it there, "Let's calm down", because there's no reason or I give a reason for the other to be doing that.Sometimes, they calm down, because then I talkt in a tone that they have to know that they must respect me (NT 1).I can handle well, sometimes I have to talk a little more seriously, sometimes I speak with more affection, but in a tone that they can understand.You must have some authority, otherwise more confusion is generated (NT 2).
Authoritarian interventions are used to ensure compliance of the elderly women and seek the solution of disagreements.It is noteworthy that the respondents use this method of action without considering the fact motivating the conflict and prioritizing its ending, to the detriment of the definite resolution.
People living in the institution tend to worry about obedience to the rules imposed by the total institutions, fearing consequences as punishment, leaving them anguished. 4In ILPE frequently residents are submissive to a staggered system of authority, that is, any professional has the power to coerce and discipline those who are institutionalized.The location of study has these characteristics, which favors the elderly to obey the orders of professionals and, therefore, cease fights and discussions.
Respondents also pointed that they make use of punishment as a strategy to manage conflicts between residents and of those with professionals.
If I saw that one has started a fight, I serve the snack to everyone, then all of them enter the cafeteria and I let that one enter last, like a child, right?And I ask: "You know why you are the last to come in?Because you did this and that".I explain very well ( NT 7).
The conduct adopted by the professional is inadequate, since punishment is an ineffective method because it prioritizes the authority and considers only their perception of the situation to carry out the action.This condition intensifies the suffering of the elderly women and is limited to punishing those who apparently began to confusion, without considering the context and the motivations that led to the occurrence of the conflict.
Another strategy used to eliminate or minimize the conflicts mentioned by nursing professionals respondents includes dialogue.
We try to talk to them separately, see what was the reason for the discussion.If it is in our reach, we try to solve the problem that caused the conflict, for example, if it is a matter of clothes, we return to the person and get another.It is necessary a whole conversation, usually there are two people (professionals), one talks with one and another with the other and try to resolve in the best way, without taking to one side or the other (NUR 1).

I talk to them, ask to calm down, not to call one of what the other called her. I talk to one, then the other, then they start calming down (NT 9).
Mediation of these situations, through conversation, requires from the professional technical and emotional skills.It is necessary for them to dedicate part of their time and to get out of their routine of tasks, to sit and chat with the elderly, have patience to listen and understand the reasons that caused the conflict without, in advance, make judgments.
It is noted the importance of the conduct which the nursing professionals adopt in the perspective of conflict resolving, in which they seek to preserve harmony and impartiality.Therefore, they are considered a source of social, emotional and affective support, aimed at the physical and mental well-being of the elderly who are under their care. 19esides offering basic care of shelter, food and hygiene, ILPE need provide its residents socialization, dialogue and interaction spaces.However, not always the professionals have the possibility of developing these actions in daily work: either due to the workloads, lack of professional or emotional stress, these have a direct impact on the management of conflicts in relationships. 20onciliation is another measure taken by nursing professionals in order to cease conflicts of the elderly women of the institution, especially when they have close bond with each other.
With roommates, you come to an extreme situation, because sometimes they are friends who like each other and end up having a discussion.We try to talk to them, there is the Psychologist who works here and sometimes helps us about it (NT 1).
There are sisters who live together here at home.In such cases where there is some kinship, a stronger connection, we try to talk and reconcile them again (NUR 1).
In some cases, the elderly women involved in conflicts are friends and share the same room or have some degree of kinship.For these, several attempts to dialogue are made in order to bring reconciliation.In case of failure, nursing professionals seek help of Psychology professional to bring back harmony among the elderly involved in the conflict, strengthening teamwork.This approach aims to strengthen the individual's own capabilities for the preservation of their mental health, that is, increasing of self-esteem, encouraging participation in social activities and engagement in tasks that encourage creativity and have personal meaning to the life of the elderly. 21nother conduct mentioned by the professionals participating in this study, is the transfer of the elderly, which caused the conflict, from one sector to another or changing room.

At first we try to talk to them and leave things as they are. If a fight or an argument happens again, we end up separating them (NUR 1).
When they start to have too many conflicts they are changed from rooms, for example, if they sleep together and start fighting, to prevent one from becoming more agitated or the other from being attacked (NUR 2).
We had to get her out of this ward, she was with this lady for many years living together and we had to take her to another one (NUR 3).
When different attempts to resolve the conflicts were not effective, nursing professionals transfer the resident causing the conflict to another room.The elderly are moved from their room or allocated in another wing, when workers can't harmonize the coexistence of those who divide the room, or when the friction affects the daily life of other residents of the same ward.However, it is considered that to transfer from wards or rooms in ILPE might not solve the conflicts, since these elderly women are able to generate other conflicts in other places.
Thus, it is understood that there are authoritarian and intimidating strategies for solving conflicts.However, other measures are based on dialogue and mediation.Facing this reality, it is important to work and reflect on the situations of conflict and the actions to be taken among the group of professionals working in ILPE, so that their conduct are oriented by the best coexistence among the elderly, guided by the respect for their identity and subjectivity.

CONCLUSION
Situations that generate conflicts are related to the real or imagined perception of the elderly women about the appreciation of the other; the dispute of their own utensils and those of common use; and the use of institutional spaces.Thus, at the moment when the residents of ILPE perceived their attention threatened, they reacted causing conflict situations.When

Conflicts among institutionalized elderly women
Bruinsma JL, Beuter M, Leite MT, Hildebrandt LM, Venturini L, Nishijima RB prevented by others to join the chimarrão circle, conflicts arose or increased.The same occurred when the elderly were moved away from their personal objects and clothes and from the places with which they sought to identify with the home prior to institutionalization.
Regarding the nursing team strategies towards conflicts in the ILPE, it was perceived attitudes which were authoritarian, intimidating and punitive.In an attempt to end conflicts, these workers used mechanisms such as changing their tones, punishment of the elderly identified as responsible for the conflicts or "ending with the problem", with the change of the resident of ward or room.Other professionals adopted strategies such as dialogue and conciliation to understand the reasons of the conflict seeking to solve them.It is noted the lack of understanding of some professionals on the identification of the reasons of the conflict, just prioritizing the end of the misunderstanding caused by the involved elderly.
The results indicate the existence of conflicts in institutionalized elderly relationships and the limitations of nursing professionals in the management of these situations that often come from the lack of knowledge and skills to deal with interpersonal relationships and difficulties in perceiving and understanding the needs the of elderly in preserving their identity.Thus, it is important to promote new strategies guided towards teamwork with an interdisciplinary approach and perception of the elderly as subject, with its history, values, beliefs and capabilities.It is possible to work with the social skills of the group of workers in order to capacitate them and discuss cases in team meetings.
Therefore, to understand the dynamics and origins of different interpersonal conflicts among institutionalized elderly women, experienced with a nursing team and the strategies adopted, seeking to train professionals who work in an ILPE, can sensitize them about the impact and implications of living institutionalized.This can enhance interventions with this public through reducing conflict in number and intensity.
It is noteworthy, as a limitation of the study, the fact that it was held from the perspective of a professional nursing staff of an ILPE that assists only women.It is suggested the expansion of studies on the thematic of interpersonal conflicts in ILPE from the point of view of the elderly, pointing out strategies for solving and facing these conflicts.