The social representations of employees of a long-stay institution in the interior of Minas Gerais regarding violence

As representações sociais de funcionários de uma Instituição de longa permanlência sobre violência no interior de Minas Gerais

Las representaciones sociales de funcionarios de una institución de larga permanencia sobre violencia en el interior del estado Brasileño de Minas Gerais

Alcione Tavora Kullok^I,i; Ivana de Cássia Baptista dos Santos^II

^IPhysiotherapist and Doctoral Student of Children's and Women's Health, Fernandes Figueira Institute, Oswaldo Cruz Foundation (Capes bursary holder). Av. Rui Barbosa 716, Flamengo, 22.250-020 Rio de Janeiro, RJ, Brazil. <alcionetk@gmail.com>
^IIPhysiotherapist, Caratinga University Center (UNEC)

Translated by David Eliff
Translation from Interface - Comunicação, Saúde, Educação, Botucatu, v.13, n.28, p. 201-212, Mar. 2009.

ABSTRACT

Brazil is going through a fast and intense process of population aging. It is estimated that 1% of elderly Brazilians are institutionalized. Despite investigative advances within the field of geriatrics and gerontology over the last decade, studies on long-stay institutions in this country are at an incipient stage and serious problems relating to quality of care are appearing. Through a qualitative, exploratory and descriptive approach, this paper investigates the social representations of employees of a long-stay institution in a municipality in the State of Minas Gerais, regarding violence at that institution. The data, from the interview transcript, were processed using content analysis. The interviewees made mention of violence and told of their sincere and deep experiences as victims. However, with regard to the elderly people, it was as if the violence always happened outside the walls, i.e. never inside the institution. Sometimes a veiled but undisclosed complaint was perceived.

Key words: Aging. Homes for the aged. Violence. Social representation.

RESUMO

O Brasil está passando por um processo de envelhecimento populacional rápido e intenso, estimando-se que 1% dos idosos brasileiros esteja institucionalizado. Apesar dos avanços investigativos na área da geriatria e gerontologia da última década, os estudos acerca das Instituições de longa permanência no país ainda são incipientes, deparando-se com sérios problemas relacionados à qualidade do cuidado. Neste artigo, de abordagem qualitativa e cunho exploratório-descritivo, foram investigadas as representações sociais de funcionários sobre violência em uma instituição de longa permanência de um município de Minas Gerais. Os dados, oriundos da transcrição das entrevistas, foram processados por meio de análise de conteúdo. Os entrevistados referiram-se à violência e relataram suas experiências sinceras e profundas como vitimas, porém, quanto aos idosos, era como se a violência sempre acontecesse extramuro, nunca dentro da Instituição, percebendo-se, às vezes, uma denúncia velada, mas não revelada.

Palavras-chave: Envelhecimento. Instituição de longa permanência para idosos. Violência. Representação social.

RESUMEN

Brasil está pasando por un proceso de envejecimiento de la población rápido e intenso, estimándose que el 1% de los ancianos brasileños está institucionalizado. A pesar de los avances investigativos en el área de geriatría y gerontología de la última década, los estudios sobre las instituciones de larga permanencia en el país son aún incipientes, afrontando serios problemas relacionados con la calidad del cuidado. En este artículo, de aproximación cualitativa y cuño exploratorio-descriptivo, se investigan las representaciones sociales de funcionarios sobre violencia en una institución de larga permanencia de un municipio de Minas Gerais. Los datos, oriundos de la transcripción de las entrevistas, se han procesado por medio de análisis de contenido. Los entrevistados se refieren a la violencia y relatan sus experiencias sinceras y profundas como víctimas. Sin embargo, en relación a los ancianos es como si la violencia siempre sucediera extra-muro, nunca dentro de la institución, percibiéndose a veces una denuncia velada aunque no revelada.

Palabras clave: Envejecimiento. Hogares para ancianos. Violencia. Representación social.

INTRODUCTION

This paper is the result from a study in which the aim was to identify the prior knowledge among the employees of a long-stay institution for elderly people regarding types of maltreatment. This was one of the problem-posing items for preparing a capacitation course for the multidisciplinary team, named "Institutionalized aging and reappropriation of identity". The course was commissioned by the institution, in conformity with Article 18 of the Elderly people's Statute, which provides for professional training and capacitation, along with guidance for caregivers, family members and self-help groups. The course also had the aim of preparing all the institution's employees for them to provide care for these elderly individuals with new eyes, placing new meanings on care practices, taking into consideration the repercussions of biological aging, the pathological conditions that might accompany aging and the social responses that determine attitudes of rejection or welcome.

It has been estimated that 1% of Brazilian elderly people are institutionalized, with various levels of dependence (Chaimowicz and Greco, 1999). According to the National Household Sampling Survey (Pesquisa Nacional por Amostra de Domicílios; PNAD) of 2001 (IBGE, 2005), there are 1.5 million dependent elderly people in Brazil. Within this scenario, with growing numbers of elderly people with chronic-degenerative diseases who are dependent on one or more people to cope with their inability to perform activities of daily living, there is also a concentration of healthy aging. Brazil is going through a rapid and intense process of population aging, and this population segment is expected to reach 15% by 2020 (Camarano, 1997).

Despite investigative advances within the field of geriatrics and gerontology over the last decade in Brazil, studies on long-stay institutions are still at an incipient stage. Moreover, today, serious problems relating to quality of care are appearing, and they only come to attention through scandals in the news, such as the case of high numbers of deaths among elderly people at the Santa Genoveva Clinic, in Rio de Janeiro. Such events give rise to concern and are a target for investigations by health sector researchers (Guerra et al., 2000). This situation demonstrates that there is an urgent need for investigations on living conditions among institutionalized elderly people in Brazil. Recent studies (Born and Boechat, 2006; Kullok et al., 2006; Machado and Queiroz, 2006; Papaleo Netto, 2006) have demonstrated that serious problems exist among dependent elderly people, such as: pressure ulcers, malnutrition, urinary incontinence, pain, negligence and maltreatment. Machado and Queiroz (2006) suggested that elderly women in situations of cognitive, physical and mental impairment are potential victims. Elderly people who are dependent on care provided by family members may suffer verbal and even physical aggression, leaving them feeling very guilty. Debts of reciprocity give rise to ambiguous feelings that may lead to aggression. Such responsibilities are based on the standards of "filial obligation" and "family obligation", and result from moral and religious codes, such as within Judaism, Christianity, Confucianism and Buddhism, among others (Aboderin, 2004; Kemp, 2003).

Intergenerational exchanges continue to be a basic characteristic of family relationships in modern and postmodern societies. Their content and intensity and the direction of the flows are some of the characteristics to be considered in reconstituting the relationships between the generations. In a general manner, the exchanges take shape around the affective domain, domestic and financial help, custody of the children and general care in cases of illness or incapacity. These include "give and take", length of time living together and providing care, services at various levels and, perhaps, the exchange that is most easily accounted: financial help and gifts (Brandão, 1999; Gil, 1999; Attias and Donfut, 1995).

The Pan-American Health Organization (PAHO, 1996) has declared that violence, because of the number of victims and magnitude of sequelae that it produces, has acquired an endemic nature and has been converted into a public health problem. Another legal milestone of major importance was the inclusion of maltreatment of the elderly in the action plan document of the Second World Assembly on Aging, which was held in Madrid in 2002 (articles 98 and 100).

In Brazil, this issue only started to arouse interest within the scientific community from the 1980s onwards. This growth in interest occurred particularly due to two factors: greater awareness of the values of life and citizens' rights; and changes in the morbidity-mortality profile worldwide and in Brazil. Among studies on violence, maltreatment of the elderly was the last type to be considered as a matter requiring policies and as a public health issue, after studies on violence against women and children (Machado and Queiroz, 2006).

In this respect, it was decided to use the international consensus among all the countries participating in the International Network for Prevention of Maltreatment among the Elderly, as endorsed by the World Health Organization (WHO, 2002) and by an ordinance of the Brazilian Ministry of Health in 2001. The prerogative in this option is to preserve homogeneity of concepts. Seven types of violence are defined: physical abuse or maltreatment involving use of physical force that potentially produces an injury, wound, pain or incapacity; psychological abuse or maltreatment involving verbal or body-language aggression that has the aim of terrorizing, rejecting or humiliating the victim, restricting his freedom or, furthermore, isolating him from social contact; negligence, consisting of refusal, omission or failure by the person responsible for the victim to provide care; self-negligence, conceived of as conduct by the elderly individual that threatens his own health or safety, with refusal or failure to provide adequate care for himself; abandonment, described as absence or desertion by the person responsible for providing the necessary care for the victim, when this person had the duty to provide physical custody and care; financial abuse of elderly people, which occurs when there is improper or illegal exploitation and/or use of the individual's financial resources without consent; and sexual abuse, consisting of sexual acts or foreplay in a heterosexual or homosexual relationship that has the aim of stimulating the victim or using him to obtain sexual arousal, and erotic sexual acts imposed through enticement, physical violence or threats.

All of these forms of interpersonal, community-based and structural violence are taken here to be expressions of absence of the elderly individual's rights.

Estimates regarding abuse of elderly people are difficult to obtain because of the frequently concealed nature of the problem. This underreporting is often associated with solitude, isolation and a tendency among elderly individuals not to report their adversities (Kosberg, 1988).

There is little evidence about how to effectively suspect or recognize the presence of abuse, and few healthcare professions actively monitor patients who do not have any apparent injuries (Rathbone and Voyles, 1982).

The players involved in the web of violence are often linked through kinship ties, which end up masking the violence or impeding detection of all the elements that form it. Minayo and Souza (2005) cited a study by WHO/IPEA (Missing Voices), in which it was highlighted that elderly people rarely speak about the violence that they suffer. They pointed out that if dependent, bedridden and aphasic elderly people living in long-stay institutions who under the care of individuals with affective ties of kinship suffer maltreatment at the hands of these caregivers, they have no one to turn to or to make complaints to. Thus, these elderly people would represent "missing voices".

One important fact is that there is no great knowledge of the realities of maltreatment of elderly people institutionalized in Brazil (Machado and Queiroz, 2006). In this paper, the verb "to institutionalize" is used in the sense of placing someone in or entrusting someone to the care of a specialized institution (Ferreira, 1999; Michaelis, 1998). This model appeared in Europe in the sixteenth century, with the aim of providing shelter for lunatics, vagrants, outlaws and elderly people. Given the negative stereotypes associated with poverty, abandonment or family rejection, one way of making these terms sound better that has been used both in public and in private institutions is to replace them by others such as elderly people's homes, houses of rest, geriatric clinics, grandmothers' houses or guesthouses for the elderly, among others.

The current rates of institution use range from 4% to 7%, in countries like Canada (6.8%), United States (4%), Israel (4.4%) and South Africa (4.5%). In China, the expectation of institutional care for elderly people is becoming the norm. In Taiwan (China), institutional care for elderly people has rapidly exceeded family care (Lemos and Medeiros, 2006).

In Latin America, the rates range from 1% to 4%. In Brazil, it is estimated to be 1%, according to the Ministry of Health. Care for elderly people in specialized institutions in the countries of Latin America is considered by their families to be a possible option. State-sponsored asylums, i.e. enormous institutions similar to the former poorhouses of England, have become transformed into smaller establishments, with multidisciplinary professional staff.

In Brazil, types of protection and care for elderly people are provided by public and private institutions. The care provided by long-stay institutions is focused, as a priority, on the neediest portion of the elderly population, and such institutions are present in the great majority of communities, in the form of traditional old people's homes and shelters (Siqueira, 2007; Lemos and Medeiros, 2006). Although there is no doubt regarding the need for qualified staff in order to ensure quality standards in long-stay institutions, many of them (and especially those of charitable nature) struggle continually with limitations of a financial nature (Born, 2007).

One of the biggest problems encountered in reconciling the ideal with the essential minimum requirement for ensuring satisfactory attendance for elderly people lies in the great difficulty in defining standards of functioning.

In 2005, technical regulations for how long-stay institutions for the elderly should function were decreed, with the aim of defining minimum criteria for functioning and assessment, along with mechanisms for monitoring such institutions, and criteria for preventing and reducing the risks to health to which elderly people living in long-stay institutions are exposed. Furthermore, the regulations guaranteed all the rights for this elderly population that are assured for them in the current legislation.

The group investigated here, living in a philanthropic long-stay institution run by a religious community, fell within this context of needy elderly people.

Material and method

The present study was conducted in a long-stay institution for the elderly, in a municipality in the state of Minas Gerais. The institution presented the following characteristics: an external area with houses for independent elderly people and an internal area divided into two separate wings (a female area providing accommodation for 40 elderly women and a male area, with thirty elderly men). Twenty-seven of these elderly people (10 men and 17 women) were reliant on wheelchairs, and the remainder presented partial dependence for carrying out activities of daily living (ADLs).

In this study, the guidance contained in Resolution 196/96 of the Ministry of Health were observed, both with regard to ethical issues with the institution that authorized the investigation, and with regard to the subjects who conceded interviews after they had read and signed the free and informed consent statement. The study participants were informed about the objectives of the investigation and the possible uses of the information gathered for subsequent studies, and they were given assurances regarding anonymity.

The participants were laundry employees, caregivers for elderly people, nursing technicians, cleaners, cooks and the secretary, president and vice-president of the institution, thus totaling 13 interviewees.

All the interviews were at arranged times, and around 30 days were needed to conclude them. They were recorded on cassette tape and were subsequently transcribed and reviewed. The interviews were conducted by two researchers with experience of caring for the elderly, and were held at the institution.

The simple mean age was 41.6 years. The participants' schooling levels were mostly between five and eight years, but one of them was illiterate and only knew how to write her name because her son had taught her. The mean length of time working at the institution was ten years and eight months.

The study undertaken took a qualitative approach, of exploratory-descriptive nature, in order to investigate the social representations of violence among the employees and directorate of the long-stay institution of this municipality. The data from the interview transcriptions and communications of the long-stay institution were processed by means of content analysis (Moraes, 1994). The units of meaning that were identified during the content analysis process were coded by the researchers as D for directorate and E for employee. It was decided not to specify the nature of each employee's position so as to maintain the interviewees' anonymity.

The methodological reference point of qualitative nature that was used was that of social representations as a methodological procedure. Social representations "[...] consist of social knowledge that positions

Individuals in the world and thus defines their social identity: their particular way of being, i.e. the product of their social being [...]" (Spink, 1995, p.8).

Based on the assumption that individuals are conceived as entireties in which the singular and social totality are indissociable, and that when subjects elaborate and communicate their representations, they resort to socially constituted significations and personal meanings resulting from their cognitive and affective experiences, Lane and Sawaia (1995) emphasized the importance of the concept of social representation as empirical data from which a dialectical analysis can be made, thereby enabling solid knowledge of the subjects' awareness, activity and identity, situated socially and historically.

Thus, the world of day-to-day life is woven through meanings that are constructed by human actions and can be interpreted. There is no a priori reality; rather, all reality is a representation that is reappropriated by individuals to form part of their value systems and is conditioned by history and social relationships (Sawaia, 1994).

In order to deepen the investigation on the perceptions, beliefs, motivations and attitudes of the employees and directors of this institution, semi-structured interviews were conducted individually to avoid situations of embarrassment, shyness or even influences on the responses.

The interview technique was considered by Minayo, Assis and Souza (2005) to be a conversation with a purpose. In the manner used in the present study, the interviewee had the possibility of speaking at length on the topic, without being held back by the questions, which served as a guide for the interviewer.

A field diary was also used, to record observations made in relation to all the contacts with the employees, highlighting any contradictions. In the analysis, the data were arranged in basic descriptive units that correlated with each other, such that patterns, similarities, differences, repetitions, themes and concepts were highlighted.

In the interpretation, we sought to attribute meanings to the analysis, and to explain the patterns encountered and identify relationships among the descriptive dimensions, in the light of detailed examination of the literature that might provide reflections relating to issues encountered and their consequences on maltreatment of elderly people.

Results and discussion

When asked "What does violence mean for you?" the researchers could feel that among the group investigated, for both the men and the women, this first question had an impact such that there was generally a moment of silence, followed by a response that was practically the same in all cases: "It's hard to say"; "Right now… it's hard"; "It's very hard to say"; "How can I say... it's gone out of my mind now..." The researchers' perception regarding this group was that for them, conceiving of violence was difficult. However, by resignifying along the lines of their representations and experiences became easier when the second question was used: "When speaking of violence, what comes into your head and into your imagination?" The participants gave the following responses: "I think it's everything that attacks the physical human being"; "Aggression, physical violence, hitting someone"; "Bad people: good people don't do violence"; "One of the worst things in the world. Of all the bad things, violence is among the worst"; "There's all types of violence"; "Lack of love"; "Screaming at someone, shoving them around"; "Women and children being beaten up"; "Mistreating other people"; "People attacking us, our boys, mistreating, getting a young girl"; "Beating up other people, doing nasty things, mistreating people".

In almost all the interviews, the word "violence" was associated with a personal imaginary populated with physical violence or physical abuse. These terms were correlated with the cycle of life and gender: children, adolescents, women and men, but at no time were elderly people cited.

This caught our attention, given that the interviewees had been working at the institution for an average of 11 years. Only one interviewee mentioned violence against elderly people, but this person had already attended a qualification course for caregivers. This person referred to psychological maltreatment: "Especially in this sector, for us working in this sector, it's violence against elderly people. We have to take care, even in the way we address an elderly person because according to the ‘elderly people's law', even if we use a higher tone, we are committing violence against elderly people"; "Verbal violence, cursing someone, or hitting them".

Another type of violence that was much cited was psychological abuse or maltreatment that involved verbal or body-language aggression, with the aim of terrorizing, rejecting or humiliating the victim, restricting his freedom or even isolating him from social contact. However, here, in these statements, it was also perceived that the words were related to the individuals' experiences and repeated experiences of a violent past: "A higher tome constitutes violence"; "Violence consists of screaming at people, not knowing how to speak to people, or drawing attention to someone in front of others. In my view, if I've done something wrong, you can call me into a corner and talk to me. If you scream at me, that's the end. You have to know how to speak positively and politely. I hate screaming: for me it's the same as hitting me, or even worse"; "Screaming".

Shouting and screaming are behavioral characteristics of interpersonal violence that occurs in public spaces like schools and companies, among others. It occurs especially within the private space of families. It occurs in a generalized and trivialized manner, but it causes disastrous consequences to people over the short and/or long term.

According to Freire (1996) and Streck (1999), such behavior takes place because of individualism and lack of dialogue. Only from starting to construct a society of oneself with everyone, with an eye to the future, and an educational process aimed towards the sense of active citizenship, with participative inclusion and justice for all, will it be possible to speak of a world at peace. The words of Paulo Freire at UNESCO, in Paris, in 1986, when he received the award "Educator for peace", are extremely illustrative: [...] Peace is created and constructed in and through overcoming perverse social realities. Peace is created and constructed in incessantly building social justice. For this reason, I do not believe in any effort called education for peace that, instead of clarifying the world's injustices, makes them opaque and attempts to make its victims myopic. Peace can only exist with justice; peace is the fruit of justice. For this reason, we speak of justpeace".

Another classification identified was that of structural violence, and 90% of the participants lived in a district in which the population of lowest purchasing power was concentrated, and which was considered to be the most violent district of the city, since it was the focus for drugs and prostitution.

"It's a violent district, with drugs, many drugged adolescents and prostitution. If measures aren't taken, the violence will just keep on increasing, and in a few days you won't even be able to go out in the streets after 9:00. You can't go out with much money for fear that someone will take it from you. For you to see, until five years ago, you heard talk of robbery in Rio de Janeiro, but today, here in such a small city, you have to go out feeling afraid. Here, it's becoming the same as in Rio. And here in our district, there's a thing like this: when you let off a firework rocket high up, everyone knows what it is: new drugs have arrived. It's their way to speak, so it's the same as in Rio. They say it's the same thing there; I've never been there, but they say it's the same thing, so here it's turning into a second Rio".

In these words, it can be seen how Rio de Janeiro is placed in the media as the model of violence, even though the city of São Paulo (capital) occupies first place in the ranking of violence in the country.

Given that the literature indicates that suffering violence is a predisposing factor for reproducing it, the aim was to ask about the violence experienced by these players over the course of their lives, through the following questions: "Have you ever suffered any type of violence?" "What?"

Although the researchers were aware that such violence, which is often concealed, might or might not be revealed, the spontaneity of the responses surprised them. One of the interviewees answered, without beating about the bush, in relation to sexual violence, that she had been raped at the age of nine years by two boys who lived in the same street. This employee had responded to the first question ("When speaking of violence, what comes into your head and into your imagination?") by promptly saying: "Like these people getting a young girl: I'm sorry for them. A young girl with a boy on her arm and he doesn't even know how to care properly." The interviewee's concern about not repeating with other people what had happened to her in the past was noted.

One of the interviewees said: "Thankfully I've never suffered this, but I've seen a lot on the television and in the newspaper".

Violence in the media, as a body making accusations, and violent programs shown in the media, have been the target of studies to indicate its positive or negative impacts, especially for children and adolescents (Minayo and Njaine, 2003). The Pan-American Health Organization (PAHO/WHO), aware that violence is a historical-social product, has emphasized the need to apply models that take into consideration each country's socioeconomic and cultural characteristics.

Other interviewees reported suffering domestic violence perpetrated by their spouse. When asked whether they had made any accusations, they said that they had not. One blamed alcohol as a way of taking the blame away from the aggressor, and the other separated from the spouse. Other studies (Deslandes, Gomes and Silva, 2000; Simão et al., 1997; Soares, Soares and Carneiro, 1996) have indicated that in around 50% of the cases of violence against the wife, the husband was drunk. With regard to making accusations, a single interviewee responded that if there was violence against her family: "How am I going to react? Do we make an accusation about the person who's doing it? If there's some violence against my family, what am I going to do? I'm not going to resolve this with my own hands: I'll make a complaint to the police"; "Mistreating the wife: this can't be allowed to happen. Husbands hitting their wives and thrashing the children: I know of many cases in which the wives were beaten up by the husbands and then made complaints, and today the husbands are in jail."

Violence in the family (parent to child) had become such a natural event that two interviewees initially said that they had not suffered this, but then they asked whether the "beatings and wallopings" that they had suffered as children should also be considered to be violence. One of them said that she had not been able to forgive her father and that, until he died, their relationship remained cut off (without speaking). This interviewee reported that she had also suffered maltreatment at the hands of not only her father but also her brothers. Physical violence perpetrated by family members within both the recent and the not so recent past provoked vivid memories, still vivid with emotion and even tears.

Regarding the men, 66% reported that they had not suffered any type of violence, and their words were the same: "Thankfully no, and I hope it never happens".

From their words, it can be gauged that they knew that they were not immune to it: a feeling of insecurity that they had when going out from their homes.

One of the men, who said that he had been a victim of violence, caught the researchers' attention, since his report had, on several occasions, been headline news in the media:

"Violence in the army barracks, we also go through it... Violence like this, in the demands of the army: they go beyond the limit. You have to do so many exercises: they double them. This doesn't respect your rights. They order you to do 30 abdominals after 90: beyond the limit."

The words of this man who had been affected by violence refers us to the original conceptualization of violence, from the Latin vocabulary coming from the word "vis", which means force and relates to notion of constraint and use of physical superiority on another person. In its material sense, the term seems to be neutral, but if violent events are analyzed, it is discovered that they refer to conflicts with authority, struggles for power and the will to dominate, take possession of and annihilate the other person (Minayo and Souza, 2005). There are manifestations of violence that are approved or disapproved and licit or illicit, according to social norms that are maintained through naturalized use and custom or through the legal apparatus of society. These and many others were practiced in military circles against new entrants and were seen in a naturalized manner, with legal objectives in conducting a career.

The question on violence against elderly people was put into the middle as a strategy for the researchers to firstly be able to gain a rapport with the interviewees. It was seen that after the interviewees had given their opinions on violence along representational and experiential lines, they all responded in a natural manner to the question: "In your opinion, what are the types of violence that are committed against elderly people?"

It was emphasized that the question related to violence against elderly people not only in institutionalized situations but also when living in the community.

Among the types of violence, abandonment came out recurrently in the reports:

"Mistreatment: leaving him alone is mistreating him"; "Abandonment"; "Elderly people aren't children either. They don't know what they are doing. There are a lot of people who hit elderly people. We see many of them here. There are some who have elderly people at home, but the family does not take care of them properly. They leave them there, put them in the house and go out and come back. Families have to look after elderly people. They gave their lives, everything, for their child, poor things"; "It's very sad because it's the same a maltreating a child because he is defenseless".

The words relating to abandonment came loaded with feelings of pity and abhorrence. One of the responses that caught the researchers' attention was a contradiction made by one of the interviewees, who initially said that he knew about violence through the communication media, but when he referred to violence against the elderly, his response was:

"Right now, I can't remember any type of violence against elderly people. No, I've never heard of it. Maybe my memory is faulty. One of my colleagues who was close to me asked whether she didn't remember the couple of elderly people who were killed out in the field. Whether she didn't remember? She answered, you know. It escapes our minds... And the couple were acquaintances of hers".

This report drew attention, because this interviewee had already worked at the institution for 11 years and was 39 years of age. When she was reminded about the event, her reaction was one of impassiveness and indifference.

Another type of violence cited was psychological, which involves verbal or body-language aggression with the aim of terrorizing. "Screaming at them"; "Hitting them and screaming at them"; "Sometimes they come with a smile to speak with you and you go and scream at him? Poor thing. It's not his fault. If we have our problems... Sometimes we aren't well... and we go on screaming at them? This is violence".

One of the caregivers started speaking thus:

"Through this course I did, for caregivers for elderly people, I discovered that that there are so many ways for elderly people to suffer violence that it's unimaginable: through a higher tone when we talk to them; through the times when the patient asks you take him to the bathroom and you reply that you can't do it now because you don't have time. Well, we're working at the institution because it has elderly people, because through them, here especially, they pay us. If the elderly people didn't exist, there wouldn't be jobs for us to receive pay, because they are retired.

This course has brought them new resignification of the process of aging with dependence, and has made them aware that they are not only direct employees of the institution, but also indirect employees of the elderly people. Therefore, if the elderly people do not deserve respect because of their age, they should at least be respected through the hierarchical grades of the institution, given that they are co-bosses.

Respect for elderly people still continues in many cultures in relation to accumulation of obtained knowledge, but in others, with technological advances, this knowledge is available through the communication media. This makes elderly people obsolete and, through this, makes them lose their space as wise individuals who are knowledge multipliers. Conflicts between the generations lead young people to take up disrespectful behavior, and this also appeared in the words: "Lack of respect, mistreatment; treating them without dignity"; "Mistreating with words, lack of respect".

Among the maltreatment items, violation of elderly people's rights was recalled: the structural violence that appears in the media all the time as news: "Elderly person beaten up in the street, waiting in line"; "Until he goes in a circular, you can note that the driver tends to turn his face the other way and pretend that he hasn't seen the elderly person, although it's the elderly person's right and it's a type of violence".

At the same time, violence leads to invisibility, during baths for dependent elderly people, as perceived in the interviews: "Get him forcibly to give him a bath"; "[...] Bath time is when you see many things happening, but we keep forgetting [...]". These words, and also the literature, indicate that negligence, maltreatment or even omission of assistance for these elderly people are among the biggest predisposing risk factors for falls (Laks, Werner and Miranda-Sá, 2006; Santos et al., 2006).

In the above reports, what can be seen is that although the interviewees did not know the different classifications of violence, they indicated almost all of them: physical maltreatment, psychological maltreatment, negligence and abandonment. The types against elderly people that were not cited were self-negligence, sexual abuse and financial abuse.

Conclusion

Elderly people are easy targets for all types of violence because of their frailness and dependence, because they do not know who to turn to and because of a lack of active legal support, despite the existence of the Elderly People's Statute (Federal Law 10,741/03). This poses the following questions: How can institutionalized elderly people make use of this instrument in their favor? What about those whose profile includes low schooling levels, dementia and dependence, who do not have families or who are isolated from their families and from society, surrounded by people whose condition is often the same or worse? How can their rights be sought? Who can they turn to, to defend them? Poor elderly people in institutions still constitute an excluded population with double invisibility in relation to society.

When the interviewees referred to violence, they almost always reported their sincere and profound experiences as victims. However, with regard to the elderly people, it was as if the violence always occurred on the other side of the walls and never inside the institution, or sometimes a veiled accusation, in the shadows but not revealed.

The aim of this study was to analyze the social representations of a multidisciplinary team regarding the topic of violence within the scope of their work, with learning of and sensitization in relation to care practices, with the aim of minimizing the impact of violence on the health of the elderly people in this institution. The item of violence was one of the topics to be investigated in order to understand the webs and their overlapping in the process of biopsychosocial and legal aging. Through the proposed reflective action, it became possible for the interviewees to assess their work, thereby transforming them into active and participative subjects who discussed and reflected on their own day-to-day actions with regard to maltreatment.

This is a small step towards an intervention process that, through using co-participative methodology, from the principle "of and through the meaning", may achieve constructive results that mobilize and transform.

COLLABORATORS

The authors Alcione Távora Kullok and Ivana de Cássia Baptista dos Santos participated equally in drawing up this article, discussing it and writing and reviewing the text.

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