Elderly Women ' s Perception about Nursing Gynecological Consultation : a Comprehensive Analysis

Objective: To understand the meaning of Nursing Consultation for elderly women assisted at a School Clinic in Mountain Region-RJBrazil. Method: It is descriptive and exploratory qualitative study, supported by theoretical and methodological framework of Alfred Schutz through sociological phenomenology. We performed 19 interviews with elderly women aged 60-80 years. The interviews were conducted after the gynecological nursing in an Ambulatory School. The data were analyzed through the participants' speech. The study was approved by the Ethics and Research Committee of the Arthur Sá Earp Neto Faculty on April 11, 2015 under Opinion number 1.019361. We used phenomenological interview.


Introduction
Elderly population aged 60 years or older has been growing in recent decades in Brazil.This rapid growth has political and social impacts, reflecting the consequent increase in the cost of health services, because this is the population that most need these services, as appearance of pathologies part of aging process.In this phase of life, there is a significant loss about 1% per year of structural and functional of different organ systems [1].
In this context, advancement of pharmaceutical industries as well as decline in infant mortality are notable factors contributing to increased life expectancy.In Brazil, between 2005 and 2010, the rate of people non-surviving up to one year of age was 22.5, and by the year 2013, the infant mortality rate dropped to 15 per thousand live births [2].
Therefore, in addition to the decline in infant mortality, an increase in life expectancy at all ages has been observed.For men and women born in Brazil, life expectancy increased from 74.6 years in 2012 to 74.9 years (74 years, 10 months and 24 days) in 2014 [3].In 2014, the elderly in Brazil accounted for 13.7% of the population -27.8 million people aged 60 years or older [4].In 2050, it is estimated that this number will reach 64 million; almost 30% of the population [4].In the world, the estimate is 21% of the population, which corresponds to 2.02 billion elderly.Brazil is in the 58th place in world ranking [5].
In response to this growing and accelerated increase in life expectancy and decline in infant mortality, the Brazilian government through Ministry of Health created a number of effective health policies that seek to meet specific needs of elderly adults in order to minimize damage to this age group associated with skilled and specialized care from health professionals [6].
The Elderly Statute was created to ensure rights of this population, as provided in the law 10.741 of October 1, 2003.Chapter IV deals with right to health, and comprehensive care provided by Unified Health System (SUS) that must be assured the elderly, as well as prevention, promotion and treatment for health with geriatric assistance in outpatient services [6].Program for Comprehensive Assistance for Elderly -PAISI was established in 2001, and in 2006, National Health Policy for Elderly (PNSPI) was established [5,7].
However, human longevity outside Brazil is already studied and public policies in this area are in force for longer time.For example, in 1982, I Assembly on Aging took place in Vienna, Austria, and in 2002, II Assembly on Aging in Madrid, Spain.These events aimed to make governments assume and establish commitments to meet challenges of the aging process and promote health and wellbeing with conducive and favorable environment, ensuring full protection and promotion of human rights of elderly population worldwide [8,9].
There are several models of social protection in force in Europe.The Scandinavian model of intervention is specifically of the State.Family is not responsible for ensuring the well-being, making it possible, on the one hand, to strengthen families (exempting them from obligations) and, on the other hand, to promote greater individual independence [9].
In Brazil, family and society along with the state, are all responsible for ensuring effectiveness rights in the Elderly statute.They have the duty to inform the competent authority about any form of violation of this Law who that they may have witnessed or that may have be aware of [8].
In Brazil, nurses are properly able to perform nursing consultations as established in their Law of Professional Practice 7498/86, regulated by the Decree 94406/87.Nursing consultations are exclusive responsibility of these professionals.Nurses are allowed to collect data and information about previous and existing diseases, basic human needs, carry out identification of risk factors, physical examination, prescription of nursing care, prescription of laboratory tests and medicines established in primary health programs and in routine approved by health institutions, implementation of nursing care and care evaluation [10].
In this context, during the Nursing Consultation, it is important to note emotional and physical state of elderly woman, establishing a positive atmosphere of acceptance and empathy for the purpose of performing Assistance of nurses in every dimension as a tool for health promotion and prevention of illnesses, allowing care to minimize complications in medium and long term [8,11].
According with Rosa (2015): During the Nursing Consultation, nurses are responsible for improving the life of the customer; they are concerned with responding to the problems identified through the diagnoses that result in resolving actions with effective strategy for early detection of health deviations, and can be performed when the individual and/or community has no health problems, as Nursing Consultation works in health promotion and transformation of social reality [12].
Thus, as stated by Rosas (2003), the world today need nurses able to diagnose community health problems and take preventive measures.Nurses, besides providing care to their patients, encourage them to perform self-care, promoting this way the general health of population [10].
Thus, the gynecological nursing consultation meets the comprehensive of women, according to uniqueness of each phase of women's lives, whether teenagers, adults or elderly.In this perspective, it is not difficult to find older women seeking consultations with signs of depression, sadness, loneliness, and so forth.It is necessary to be attentive to subjectivity of each woman, trying to provide comprehensive care and understand main reason that led them to the query.
In this context, informing, assuring the rights of elderly women and encouraging the compliance with their duties in society is part of Caring Acti-vity of nurses, as well as encouraging socialization, practice of physical exercises, enhancement of selfimage and other aspects.Nursing Consultation is not restricted to sick people.It goes beyond the care provided for individuals; it is an activity that can also provide self-worth, self-esteem and citizenship [8,11,12].
The study is important and current because elderly population is increasing, and aging is result of social and technological development worldwide.Even with social inequality and poverty, which is mainly present in underdeveloped and developing countries, the life expectancy is increasing [13].
An aspect to be highlighted in relation to Brazilian demographic movement is feminization of aging -largest proportions of women occur at older ages.This is explained by higher male mortality resulting from accidents, violence and increasing tendency to develop chronic diseases earlier than women [14].
According to Brazilian Institute of Geography and Statistics (IBGE), by year 2050, the elderly will represent a fifth of world population.An increase of about 8 million older people has been observed each year.So, in this period, projections indicate that elderly population will be 1,900 million resulting in a phenomenon never seen before: there will be more older people than children [4].
In this context, research studies have shown a lack of published materials related to the health of elderly woman.An integrative review revealed that health policies are geared at women who are in age group of 10-49 years, and there are few publications about elderly woman health when compared to other age groups.[15] Thus, the present paper has the following objective: To understand the meaning of Nursing Consultation for elderly women assisted in a School Clinic in the Mountainous Region of Rio de Janeiro, Brazil.

Method
It was used a descriptive and exploratory qualitative study of based on sociological phenomenology of Alfred Schutz, to grasp the meaning of Nursing Consultation for elderly women assisted a School Clinic in the mountainous region Rio de Janeiro.Brazil.
"The Sociological Phenomenology of Alfred Schütz is based on living the experience, that is unique and only the subject of the action can say what is intended when carring it out.And that every action is intentional.Therefore, every action has meaning" [16].
The study included 19 women aged over 60 years assisted in Nursing Gynecological Consultation.The instrument used to obtain testimonies was the phenomenological interview following approach questions: What is in your opinion Nursing Consultation?What does Nursing Consultation means for you?What do you have in mind when it comes to Nursing Consultation?Interviews were recorded on mobile phone in MP3, and after each interview were immediately transcribed to obtain the meaning of Nursing Consultation for women assisted in a School Clinic of the Mountain Region -RJ.
Besides interview was collected data about the participants such as: identification, age, educational level, menarche, menopause, number of partners in life, condom use (past/current), hormone replacement (past/current), smoking habit, and sexual activity.All these aspects served to trace biographical data of the interviewees.
All interviews were voluntary and had prior authorization for dissemination of results, after obtaining the Informed Consent (IC) of participants, according to Resolution nº 466/12.Anonymity of all participants was maintained, and they were identified only by the letter I followed by the serial number of the order of interviews, following principles of individuality and research ethics.
In this study inclusion criterion were: women aged over 60 years who have been meet the ne-eds in Nursing Gynecological Consultation.And as exclusion criteria: women who missed the consultation in the day of interviews.
This study is part of a research project entitled: The meaning of the Nursing Consultation for women assisted in the outpatient clinic of the Faculty Arthur Sá Earp Neto.

Results
The study allowed to know aspects that helped in building categories.According to phenomenological approach of Alfred Schutz, this kind of research is closely connected with social relations, and for this, it was necessary to know biographical data of study participants [16].
About the age of participants, nine of the respondents were aged 60 to 65 years, three are between 66 and 70, five between 71 and 75 and two between 76 and 80.About education we observed that thirteen women did not complete elementary school, five completed high school, and one is illiterate.Only three reported being smokers.
Regarding the menarche, seven started the menstrual cycle between nine and eleven years old, six between 12 and 14, and six at 15 years or more.About number of partners in life, 17 elderly had 5 partners, one had 10 partners and one had on average 50 partners in life.All participants in this study are in menopause and reported not undergoing (in the past or present) hormone replacement.
In this sense, thirteen women said not to be sexually active and six were sexually active.Regarding use of condoms, only five refer to use it.An important fact is that 14 women reported that when they were sexually active, they did not use condoms.This made them vulnerable to contracting sexually transmitted infections.
It is worth noting that, according to DATASUS data, between 2005-2014, only in the state of Rio de Janeiro 372 cases of AIDS were reported among older women, aged 60 years or more.[17] Thus, by the biographical profile of participants we can suggest that development of educational activities for these women may result in promoting health and disease prevention.
Responses obtained from elderly helped for an understanding of women's experiences during Nursing Consultation.From these responses, we developed three categories that reveal the meaning for this social group when searching for Nursing Consultation: "To be well assisted", "To have resolving power" and "To prevent health problems".

Category I. To be well assisted
In the first category, it was clear that during Nursing Consultation women feel welcomed, and they are heard, and for this reason, they say that are well assisted.Regarding the women to be heard allows the exchange of information between patient and nurses.When establishing a link, the nurse has opportunity to offer support that may result in opportunities for women to take care of their own health.
Thus, we identified in the speeches of participant that nurses and older women establish a typical community relationship between them.We believe that this approximation allows an open dialogue, and makes it possible to decrease vulnerabilities of this social group which, according to the biographical data, is sexually active and do not use condoms in general.The elderly feel well assisted, and for this reason they seek Nursing Consultation to expose their needs.

I1.
It means that I am treated well here, I'm much loved by the girls here.I also like them.There is always that affection.Sometimes, in other consultations, we go and we are not well treated.Here (Nursing Consultation) we are treated well in all.

I2.
I think it's great, the girls always treated me very well, and always give me congratulations, I think it's great.

I3.
The fact of being heard during consultations also allows them to hear the nurse, and they are guided on what is done during consultation, and what they can do to have quality of life.When nurses congratulate women because they received guidance and were able to put it in practice, both share responsibility of care.

I like it very much. Everyone here treats me very well, I cannot complain about anyone here. All queries, not only of nursing, all of them.
I5.

During Nursing Consultation I was very well assisted.
I6.

I7.
They are very nice, I am well assisted, then, it is good.

I11.
I have always been well assisted, thank God.

I12.
They are so nice, right?! I like, nice girls.

I13.
All women, during nursing consultation, said they were well assisted.They highlight education treatment, care and respect with which they are received.This enables the understanding that, during that moment, nurses value of human being.

Look, I think it's great! Now I'm feeling very well.
I14.
Nurses here are very polite, they leave the patient at ease.Their assistance is not ten, is one thousand.They are cute girls, all of them.I15.

I have nothing negative to tell about the nurses. Nurses always took care of me very well.
I16.

I18.
Well, the goal is to be well assisted, and I have been well assisted here.That's it.

I19.
Assertions show that there are nothing to complain nurses' approximation with this social group.This facilitates exchanges experiences between who provide care and those who receive care.The importance of humanized care is to see women with comprehensiveness, contributing to the service so that it can go beyond providing assistance in a technical manner; the attention becomes exclusive, respecting elderly'.

Category II. To have resolving power
In the second category, elderly women assisted in Nursing Consultations at the Clinic School wish to find solution for their demands.These include collection of cytological examination, request of examinations, prescription of medicine according to protocol of the Ministry of Health in Brazil, and when necessary, referral to other professionals and scheduling return visits.
Ah, this mean much, because they re-schedule the query to me, then they assist me very well.For me, they are great.

I3.
To be assisted to solve a health problem.

I4.
I'm eager to get the consultation, because it has been difficult to get a query.

I5.
I want to recover from my diseases.

I9.
During Assistance Activity of nurses, women seek answers to their complaints, they refer difficulty to receive care because of amount of places available are not enough for the patient's demand.As soon as they have Nursing Consultation they see that nurses have skills and expertise to provide what they need.
For me I think it is better because I do not need to go to queue again.I can solve everything.

I10.
When I come here, I come to be medicated.

I16.
We know that nursing has a higher attendance today than formerly.Right?! We can get a preventive material.In the past, there was no such a thing, today the nursing has it.So I think it's very valid to seek the nursing consultation, I find it necessary.

I17.
In addition to the care provided with a differentiated look, being kind and welcoming, the lines show nurses' ability to provide solutions and results for older women.It is worth mentioning the speech of the interviewed 17 when she highlights the emotional support that the nurse dedicated.
Thus, nursing professional has technical-scientific skill and is able to provide quality of care to older women, not leaving aside the emotional support.

Category III. To prevent health problems
The third category is about the prevention of diseases as intention of women when they seek for Nursing Consultation.Thus, we can see a change in the behavior of this social group that no longer seeks the health service only to treat diseases but also to prevent them.
The World Health Organization (WHO) defines health as a state of complete physical, mental and social well-being, not consisting merely on the absence of diseases or infirmities [18].Validating this concept, women is highlighted during nursing consultations, encouraging them to keep vanity, emphasizing the value of life in old age which offer opportunities rarely available during youth, such as traveling, study, dedicate time to leisure, aspects that can contribute to well-being in different areas.
It means everything, right?! My health, my wellbeing.For me, it is all.

I1.
I come here to make a check-up, to see if I am doing well and to avoid sickness, right?! I do treatment, I am always here.

I7.
I used to take care of my mother and my husband and I did not take care of myself.I spent 4 years without coming to the health service.He (husband) died and now I need to take care of myself.

I8.
This social group believes that be attended in nursing consultations, it is possible to prevent common diseases among women.In nursing consultation they cite mammography, wish to have healthy life, and learn about food.In view of these reports, the educational character of the actions of nurses is clear.This face to face relationship where these professionals care and teach offers possibilities for women to take care of their own health.
To ask mammography, receive treatment.

I9.
I take care of myself, I want to have a good health, to live longer.Having a healthier life.Learning how to eat right, to take care of myself.

I15.
It is one more prevention of women's health.That's how I see it, you know?! To receive preventive orientation from the nurse, collect material, it is preventive, prevention of cervical cancer has been very stressed, as it can appear suddenly and the person does not know.And if I am doing preventive treatment, then I am being followed every year, preventing.Is it not true?! I17.
In this sense, education can also be an activity of nurses, guiding and clarifying questions in order to make each individual active promoting health and disease prevention.Nurses should detect risk factors to which individuals are vulnerable, identify signs and symptoms for early detection of diseases as well as to contribute to adherence to treatment, resulting in favorable actions that will help elderly woman to live better.

Discussion
The speeches of the participants in this study helped to understand the experiences of elderly women seeking care in Nursing Consultation.Based on these, it is possible to develop strategies to provide care in a singular manner for this social group.
Life is a particular way of seeing and being inserted in the everyday world; that world is full of feelings, experiences, expectations, difficulties, and each one lives a private world.Thus, each woman has her individuality, a way of perceiving the universe in which she is inserted, what is called by Schutz as Subjectivity [19].
Elderly women rely on a Intentional project when they go to Nursing Consultations.For this, they present Reasons, called by Schutz [20,21] as "reason for" and "reason why".The "reasons why" are related to the contextualization of the project.It is about events already completed.Events accessible to the observer.In turn, the "reasons for" is the projection for the future of the intentional action.
By knowing the Typical Action, it is possible to know the meaning that this social group attributes to a phenomenon.This entire process happens in a face to face relationship.Woman -nurse [16,21].
Before the results of this study, after finding the "reasons for" contextualized by the "reasons why" evidenced through the type of experienced lived by the social group studied, we note that nurses can offer this social group good care and so establish link in a face to face relationship, making it possible resoluteness to their demands and contributing for them to have a better quality of life by promoting the health of these women.
In this overview of health care activities, nurses can develop a face to face relationship during nursing consultations, where both are subjects of their actions, exchange knowledge and share experiences [10].
In this sense, "The performance of health care activities of Nursing Consultation requires domain of content and acquisition of motor and intellectual abilities, but it is fundamentally a relationship with the other" [10].
"For Schutz, social face to face relationship is a direct relationship and establishes a typical community relationship, in which the subjects face each other sharing the same situation of space and social time" [16].

Conclusion
The results pointed out that the Nursing Consultation promotes an approximation between women and nurses, establishing ties, evidenced in the results.
During the Nursing Consultation, it is necessary to get rid of prejudices and beliefs in order to meet the basic human needs, and insert it into society, in the family context and guide on the rights and duties of elderly women as citizens.It should not be forgotten, however, that besides providing security, it is also important to interact with the elderly woman, acting with empathy and contributing to the harmony between body, and mind.
It is suggested that other studies be approached the perception of the professionals who perform the gynecological nursing consultation.The limitation of the study is in few publications on gynecological nursing.
It was approved by the Ethics and Research Committee of the Faculty Arthur Sá Earp Neto on April 11, 2015, under number 1019361 and CAAE: 43536715.1.0000.5245,respecting the Resolution 466/12 that deals with research involving human beings.Data were collected in June and July 2015.