Pensar Enfermagem / v.29 n.Sup / Jan-Dec 2025
DOI: 10.71861/pensarenf.v29iSup.431 / e00431
How to cite this article: A Godinho M, Sousa E, Vieira A. Empowering Formal Caregivers in Residential
Care Facilities for the Elderly to Provide Safe Care – Intervention of the Community and Public Health
Nurse. Pensar Enf [Internet]. 2025 Jan-Dec; 29(Sup): e00431. Available from:
https://doi.org/10.71861/pensarenf.v29iSup.431
Quantitative Original Article
Empowering Formal Caregivers in Residential Care
Facilities for the Elderly to Provide Safe Care –
Intervention of the Community and Public Health
Nurse
Abstract
Introduction
The current national demographic reality shows a significant aging of the population, with
a growing number of elderly individuals residing in Residential Care Facilities for the
Elderly (RCFE), leading to an increased need for formal caregivers (FC). The literature
indicates that the lack of skills among FCs in RCFE affects the quality of care provided,
with direct impacts on resident safety. By assessing the knowledge level of formal
caregivers, it was possible to structure an intervention aimed at empowering them.
Objective
Empowering formal caregivers in Residential Care Facilities for the Elderly to provide safe
care in the intervention area of a Community Care Unit (UCC).
Methods
The methodology applied was based on Health Planning grounded in Betty Neuman's
theoretical framework, the Systems Theory. The foundation of the project based on
scientific evidence was supported by a Scoping Review according to the methodology
proposed by the Joanna Briggs Institute (JBI. The tool used for the situational assessment
was a questionnaire developed by researchers and administered to formal caregivers to
identify their training needs. A non-probabilistic convenience sample was comprised of 161
formal caregivers. To ensure compliance with all ethical, deontological, and methodological
principles, this intervention project was developed following a favorable opinion from the
Health Ethics Committee (HEC) under reference 51/CES/INV/2023.
Results
The situational assessment revealed a compromised caregiving capacity due to a lack of
knowledge about the contents of the first aid kit, checking the first aid kit, procedures in
case of an accident, first aid, and maintenance of the cold chain. Health Education and
Health Communication were used as intervention strategies. Evaluation, based on process
and outcome indicators, shows positive contributions to the empowerment of formal
caregivers, reflected in 84% of caregivers identifying how to act in case of an accident, 94%
identifying when to place someone in the recovery position, and 82% identifying the Basic
Life Support algorithm.
Conclusion
This project contributed to the empowerment of formal caregivers through community
nursing intervention, as well as providing insights into how to develop interventions with
formal caregivers in Residential Care Facilities for the Elderly to empower them to provide
safe care.
Keywords
Formal Caregiver; Empowerment; Community Nursing.
Maria Filomena Godinho
orcid.org/0009-0007-2445-3353
Edmundo Sousa2
orcid.org/0000-0003-2136-4471
Ana Vieira3
orcid.org/0000-0002-6759-091X
1 Master. Centro de Sangue e Transplantação de
Lisboa, Instituto Português do Sangue e
Transplantação, IP, Lisboa, Portugal.
2 PhD. Departamento de Enfermagem de Saúde
Comunitária, Escola Superior de Enfermagem de
Lisboa, Lisboa; CIDNUR - Centro de Investigação,
Inovação e Desenvolvimento em Enfermagem de
Lisboa, Lisboa, Portugal.
3 Master. Unidade de Saúde Pública Francisco George,
ULS Santa Maria, Lisboa, Portugal.
Corresponding author
Maria Filomena Godinho
E-mail: mariafilomenagodinho@gmail.com
Received: 15.03.2025
Accepted: 25.07.2025
Editor: Pedro Lucas
Godinho, M.
Quantitative Original Article
Introduction
To care is a verb that is present throughout our existence,
we care, we are cared for, and we watch over the care of
others.1
According to Manuel et al.2, the caregiver emerges from
mutual help, defining caregivers as “someone who carries
out activities aimed at the personal care of someone with a
certain degree of dependency”. (p.2) Moreira et al.3 defines a
caregiver as one who “must be empowered to perform
basic hygiene care, provide feeding conditions, help with
locomotion and create alternatives that provide the patients
in their care with a better quality of life”. (p.2)
According to the WHO4, a formal caregiver is defined as
someone who helps people with one or more disabilities,
who belongs to an organization (profit or non-profit,
governmental or private), or someone (excluding family,
friends or neighbors) who provides regular and paid-for
assistance, but who is not associated with any organization.
Since there is no single definition of formal caregiver,
unlike informal caregivers, it was decided to define formal
caregivers for this project as all workers, regardless of their
training, who are hired and paid to provide services in
RCFEs.
According to the World Social Report 20235, it is estimated
that in 2050 there will be 1.6 billion people aged 65 and
over, which indicates an increase of twofold compared to
the figures for 2021; moreover, it is also estimated that the
population aged 80 and over will triple in 2050 to a number
of 425 million. These figures represent a growth of 3% per
year, much faster than the other age groups. The aging of
the Portuguese population goes hand in hand with this
reality. According to the latest data available from the
National Institute for Statistics (INE)6, Portugal had an
aging rate of 178.4% in 2021, revealing that the elderly
population significantly outnumbers the young. Alongside
this indicator, the old age dependency ratio has also
increased in recent decades, standing at 36.9% in 2021. The
longevity rate, which stands at 48.7%, has also been
increasing, which means that as well as having a growing
elderly population, it is also getting older. According to
INE6, Portugal is home to 2.5 million people aged 65 or
over, and 368,400 of these are aged 85 or over, for a total
resident population of 10,467,366.
This reality puts great pressure on the responses required
from health and social protection systems. Paixão7, states
that the increase in longevity and dependence of the elderly
results in a greater need for care and, consequently,
caregivers. The current way of life of families is one of the
factors contributing to the increase in the number of
institutionalized elderly individuals. However,
institutionalization is also a way of trying to solve the
problem of loneliness and progressive incapacity, Moreira8
and difficulty in self-care. The Residential Care Facilities for
the Elderly (RCFE), defined as an “establishment for
collective accommodation meant for temporary or
permanent use, in which social support activities are
developed and nursing care is provided”8 (p.1324), focus
essentially on a model of social responses, however, the
high levels of dependency and associated comorbidities
reveal it as a model in need of renewal, where health
responses should take on a more central role. Among the
set of activities that RCFEs provide, Article 8(g) states
“Nursing care, as well as access to health care” and Article
8(h) states “Administration of drugs, when prescribed”9
(p.1325), which are the nurse's skills, set out in the Regulation
that defines the nurse's duty.10 According to the Basic
Health Law11, Base 2 “people have the right to access
healthcare appropriate to their situation, promptly and
within the time considered clinically acceptable, (...)”7 (p.56),
it is the RCFEs’ responsibility to ensure this response as a
guarantee of the safety of its residents, since one of the
aspects that most contributes to the occurrence of adverse
events for RCFE users is delayed or inadequate
intervention.12 According to the Basic Health Law11,
patient safety is one of its fundamental components, and
the State is its promoter and safeguard through the
National Health Service (SNS) or any other institution. For
the National Plan for Patient Safety (PNSD 2021-2026),
guaranteeing safety is fundamental “the implementation of
policies and strategies that reduce these incidents, part of
which are avoidable, is recognized internationally and
nationally as leading to health gains and is now an
unequivocal commitment to health”.13 (p.96) One of the five
pillars of the PNSD 2021-2026 is a culture of safety, which
“corresponds to the set of individual and group values,
beliefs, norms and competencies that determine
commitment, style and action regarding patient safety
issues”. 13(p.99) One of the challenges for the quality and
safety of caregiving is related to the qualification of RCFE
employees, Gartshore et al.14 and Pinheira et al.15, indicate
that one of the main problems related to human resources
is based on the lack of qualification for the provision of
direct care to the elderly. The training of these caregivers
mainly takes place in the workplace, given by their peers,
which can impact the quality of such training, as it is
unstructured and takes place before the start of their
duties.15
The development of societies and the knowledge they
produce requires them to be constantly updated, as well as
the permanent and deliberate process of acquiring this
knowledge with the aim of contributing to the development
of institutional competencies through the development of
individual competencies is known as empowerment. The
empowerment of formal RCFE caregivers is extremely
important to ensure that the elderly receive the necessary
care in a safe way, and the intervention of Community and
Public Health Nursing (CPHN) plays a fundamental role
here in supporting caregivers and their empowerment. It is
therefore important for Nurses Specializing in Community
and Public Health (NSCPH) to identify the needs of
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Quantitative Original Article
caregivers and the areas in which they need the most
support in relation to the needs of the elderly. For Feitor et
al16, when the client of nursing care is a community, the
community empowerment model should be adopted as a form
of empowerment, considering it a practical and valuable
working tool for community nurses. Empowering
individuals and communities to adopt healthy behaviors is
a responsibility upon which the NSCPH must play a central
role, given their favorable position in the relationship with
the individual. The NSCPH is responsible for developing
interventions that empower caregivers about what to do,
how to do it and when to do it, providing the necessary
information so that caregivers are active agents in carrying
out the interventions, contributing to the safety of the
person being cared for.
This article aims to summarize the implementation and
evaluation of a community intervention project, based on
the Health Planning methodology, which allows for the
assessment of a community's needs, their prioritization and
the evaluation of the strategies and interventions carried
out as a way of responding to these needs, developed
throughout the Master's Degree in Community Nursing,
within the field of Community and Public Health Nursing.
The project was grounded in scientific evidence through a
Scoping Review, according to the methodology proposed by
the Joanna Briggs Institute (JBI), based on the PPC mnemonic:
population: caregivers in RCFE; concept: safety and
vulnerability; context: RCFE. The CINAHL Complete and
Medline Complete databases were used, with the following
inclusion criteria: publication date equal or later than 2017,
access to full text in Portuguese or English, age + 65 years
and free access.
The general objective of this study was the development,
implementation, and evaluation of a community nursing
intervention project that would empower formal caregivers
(FC) in Residential Care Facilities for the Elderly to provide
safe care.
Methods
This is a descriptive cross-sectional study that was
supported by the Health Planning methodology, which is
defined as a continuous and dynamic process that enables,
based on identified needs, the efficient use of (often scarce)
resources17 and is grounded in Betty Neuman's theoretical
framework, Systems Theory. The health planning
methodology is divided into the following phases:
situational diagnosis; definition of priorities in relation to
the problems identified; definition of objectives and
strategies to achieve them, then a program or project is
drawn up, the operationalization is prepared, it is
implemented and at the end it is evaluated.18
The community intervention was carried out within the
area of influence of the Community Care Unit (CCU),
which serves a population of 84,85919, of whom 21,79719
are aged 65 or older. The project's target population
consisted of formal caregivers in RCFEs that belong to the
CCU's geographical area, the inclusion criteria were: formal
caregivers in RCFEs that belong to the CCU's area of
influence; formal caregivers in RCFEs with an audit report
carried out by the Public Health Unit (PHU) between
January and July 2023 and formal caregivers who agreed to
participate voluntarily in the study. The sample was non-
probabilistic and convenience-based, consisting of 161
formal caregivers.
The data collection instrument used to address the first
phase of health planning – situational diagnosis – was a
questionnaire designed by the researchers, based on the
audit reports conducted by the PHU on the RCFEs within
its geographical area of coverage, and the cross-checking of
this information with the findings of the Scoping Review,
which was validated by experts and pre-tested in an RCFE,
between 20.10.2023 and 23.10.2023, with twelve formal
caregivers. The results showed that there was no difficulty
in reading and interpreting all the items by the employees,
making it possible for them to complete the questionnaire
themselves. The instrument was divided into two parts:
Part A - consisting of five questions, aimed at
characterizing formal caregivers in terms of
sociodemographic data; and Part B - consisting of 22 areas
grouped into four main areas of intervention:
Environmental safety; Response to accidents; Drug safety;
Continuity/adequacy of care, which made it possible to
identify the training needs of formal caregivers. The
sampling process was carried out using a non-probabilistic,
purposive sample of participants, between November 15
and December 3, 2023.
In order to ensure the ethical soundness of the
intervention, a formal request to conduct the project was
submitted to the executive director of the ACeS LN
(Group of Health Centers of North Lisbon), the PHU
coordinator and the CCU coordinator. Finally, an opinion
was requested from the Health Ethics Committee (CES) of
the Regional Health Administration of Lisbon and Tagus
Valley (ARSLVT) on June 21, 2023, which was given a
favorable opinion for the diagnostic phase on November
15, 2023, through Opinion 51/CES/INV/2023. After
carrying out the diagnosis, a new request for an opinion was
made to CES ARSLVT for the intervention phase, to which
a favorable response was received on December 12, 2023.
The following phases of health planning, from the
definition of priorities, objectives, intervention, and
evaluation, which dealt with 73 FC, took place immediately
after receiving the opinion and continued until February 9,
2024. As a method of evaluating the interventions, a new
questionnaire was developed by the researchers, based on
the topics addressed during the Health Education (HE)
sessions, and applied to the FCs after the interventions had
taken place.
Godinho, M.
Quantitative Original Article
The data collected was processed using descriptive
statistical analysis, using the Statistical Package for the Social
Sciences (SPSS) program version 29.
Results
The age of the formal caregivers varies between 22 and 72
years old with an average of 43.8 years, the maximum age
corresponding to a FC who owns an RCFE. The mode is
40 years, and the median is 43 years. Looking at the
standard deviation, it is below the average (12.25), which
indicates a certain level of homogeneity within the sample.
It was found that 89% of the formal caregivers are female
and 11% are male. The educational qualifications variable
shows that 31.5% of the formal caregivers have completed
higher education and 28.8% have attended secondary
education. In terms of educational background, 16.4% of
the samples have attended school up to the 2nd and 3rd
cycle (equivalent to middle school), 13.7% attended a
professional technical course and 9.6% have only the 1st
cycle (primary education). Regarding training in the care of
dependent elderly people, 57.5% of the caregivers reported
having received training and 42.5% reported having no
training in the area. Regarding the length of time they have
worked professionally in caring for the elderly, caregivers
have an average of 9.7 years, with 0.5 years as the minimum
length of time and 35 years as the maximum. On a Likert-
type scale of 1 to 5, where 1 corresponds to “no difficulty”
and 5 to “always having difficulty”, it was found that the
areas of response to accidents and drug safety had the
highest scores, which means that these are the areas that
present the most difficulties. The results of the knowledge
assessment were categorized as: very good, good,
satisfactory, poor, and very poor. Assessing the categories
poor and very poor, the area and intervention – response
to accidents ranked first, followed by the area – drug safety.
According to the data obtained in the situational diagnosis,
and since it was not possible to intervene in all identified
areas, the problems were prioritized (the second phase of
health planning) using the adapted Hanlon prioritization
method, with the following weighting criteria: magnitude
(A); severity (B) and effectiveness of the intervention (C)18,
applied in the following formula: (A+B) x C, from which
the following nursing diagnoses emerged, according to the
ICNP® taxonomy20, 2019 release: Impaired ability to
perform caretaking due to knowledge deficit about the
contents of the first aid kit; Impaired ability to perform
caretaking due to knowledge deficit about checking the first
aid kit; Impaired ability to perform caretaking due to
knowledge deficit about the procedure in an accident
situation; Impaired ability to perform caretaking due to
knowledge deficit about first aid and Impaired ability to
perform caretaking due to knowledge deficit regarding
response procedures in the event of cold chain
maintenance.
Based on the prioritized problems, and in order to address
the third phase of health planning, general objectives and
specific objectives were defined, these were defined as the
“desirable and technically feasible outcome of the evolution
of a problem that alters, in principle, the natural
evolutionary trend of that problem, translated in terms of
outcome or impact indicators”.18(p.79) Thus, the general
objective is: Empower formal caregivers in the context of
RCFE and the specific objectives are defined as follows:
Increase formal caregivers' knowledge about the first aid
kit; Educate formal caregivers on how to respond to the
most common accidents; Educate formal caregivers in first
aid (Basic Life Support and Recovery Position) and
Increase the proportion of formal caregivers with
knowledge of the cold chain procedure.
In line with the defined objectives and in response to the
fourth phase of Health Planning – Selection of strategies,
the following health promotion strategies were chosen:
Health Education (HE), according to Rodrigues21 which
enables health literacy and empowers individuals to manage
their health, the World Health Organization4 also considers
HE to be a fundamental strategy that enables individuals
and communities to improve their health, expanding
knowledge and thus influencing empowerment. The other
strategy used was Health Communication, which enables
the dissemination of information with the purpose of
promoting health.22 This strategy included the development
of informational materials (cards, procedures) in physical
and digital format, intended for formal caregivers. After
establishing the priorities and defining the strategies to be
implemented, the themes to be covered in the HE sessions
were identified. This stage began with an approach to the
RCFE's technical directors to present the results of the data
collection, the areas subject to intervention and to negotiate
the locations, dates and times for the HE sessions. As far
as the HE sessions are concerned, an initial plan was
developed; a didactic tool (slides) was created to present the
content of the sessions; a set of cards was prepared for each
RCFE, a procedure and a short video made available via a
link for later consultation. A questionnaire was also
developed and administered at the end of the HE sessions
to assess trainees' satisfaction and knowledge acquisition,
as well as a certificate of participation and an attendance
sheet.
Evaluation constitutes the sixth and final stage of Health
Planning. “In a planning or programming situation, most
of the elements used in evaluation take the form of
indicators. It is through them that we get to know the reality
and measure the progress achieved”.18(p.178) At the end of
each session, an evaluation questionnaire was administered
on the topics covered, allowing for the assessment of the
knowledge of the formal caregivers who participated in the
HE sessions. The evaluation of this project was based on
activity and result indicators, as shown in Table 1.
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Quantitative Original Article
Table 1. Activity and results indicators.
Target
Result
70%
84%
100%
133%
Target
Result
100%
100%
80%
83%
80%
84%
90%
94%
80%
82%
80%
86%
80%
94%
Table 1 shows that the targets initially proposed for the
defined objectives were achieved in their entirety. The HE
sessions had a high level of participation from the formal
caregivers, and more sessions were held than initially
planned, at their request, to allow a greater number of
caregivers to attend. However, evaluating the results using
only a questionnaire administered immediately after the HE
sessions does not allow for a thorough measurement of
their impact, the results obtained provide evidence of
transformation, but equivocal evidence of sustained
change.
Discussion
This study aimed to empower formal caregivers in RCFE
to provide safe care, using an approach based on Health
Planning and grounded in Betty Neuman's Systems Theory.
One of the challenges to ensuring the quality and safety of
the care provided in RCFEs is related to the qualifications
of their staff. This project helped to strengthen the
mapping of scientific evidence obtained through the Scoping
Review carried out by the researchers, according to
Gartshore et al.14 and Pinheira et al.15, one of the main
problems related to human resources is based on the lack
of qualifications for providing direct care to the elderly. The
training of these caregivers mainly takes place in the
workplace, given by their peers, which can impact the
quality of such training, as it is unstructured and takes place
before the start of their duties, Pinheira et al.15
The results show that the empowerment of formal
caregivers in Response to Accidents and Cold Chain
procedures had a positive impact on improving their
knowledge. The results are consistent with the existing
literature, which highlights the importance of training
formal caregivers to improve the safety and quality of care
in RCFEs. Several authors, such as Ree et al23, point out
that increasing caregiver qualifications and improving
communication and cooperation among professionals are
critical factors for safety in long-term care. The literature
shows that a robust security culture and adequate staffing
are essential to overcome these obstacles.14 The results
suggest that, in addition to empowerment, greater
investment in human and organizational resources may be
necessary to ensure total safety in the care of the elderly.
The findings indicate that the empowerment process
contributed to a substantial improvement in caregivers'
knowledge and practices in areas critical to residents' safety.
The methodology used, grounded in Betty Neuman's
Theory, made it possible to identify and prioritize the
stressors that affect the caregivers' performance, providing a
theoretical foundation that guided both the assessment of
needs and the development of interventions. It was found
that, when guided to identify and minimize risk factors as
well as intrapersonal and interpersonal stressors, caregivers
were better prepared to respond to emergencies and to
carry out procedures safely. In a client system (FC) that is
intended to remain in balance, as a way of achieving this
purpose, the possible factors that could generate stress and
collide with the flexible line of defense and compromise the
normal line of defense were identified. The strengths of the
formal caregivers were identified with the same objective,
which in this project translated into empowering the RCFE
formal caregivers to provide safe care. Thus, the
intervention in this research was at the level of primary
prevention.
This study has some limitations that should be taken into
account. Firstly, the sample was limited to formal caregivers
from a single geographical area (CCU), which may restrict
the generalization of the results for other RCFEs or regions
with different contexts. Secondly, the data was collected
through a questionnaire administered after the HE
sessions, which may introduce a response bias, as
participants may have reported improvements based on the
expectation of what was considered adequate and it is not
possible to assess knowledge retention, changes in practice,
or actual transformation. Future studies with long-term
follow-ups could provide a more detailed understanding of
the sustainability of the improvements and the continuous
Godinho, M.
Quantitative Original Article
impact of the knowledge acquired. Another point to
consider is that the infrastructure and resources available in
each RCFE may have varied, affecting the implementation
of safety practices.
The results of this project highlight the importance of
Nurses Specializing in Community and Public Health and
the use of strategies such as Health Education sessions in
continuous empowerment and in interventions focused on
the safety of formal caregivers in RCFEs. The literature and
the findings of this study indicate that developing skills in
the areas of safety and first aid, by integrating standardized
protocols and continuous assessment tools, can have a
direct impact on the quality of care provided and the safety
of residents. RCFEs should, therefore, consider
implementing periodic and updated training that addresses
the specific needs of caregivers and aligns with the
principles of the National Plan for Patient Safety.13
This study opens doors to further research that could
explore the effectiveness of continuous empowerment
programs in RCFEs in other regions and with a larger
sample. Moreover, longitudinal studies that monitor the
impact of these empowerments over time are
recommended to verify the persistence of the results and
identify areas needing reinforcement. Another area of
interest would be to investigate the relationship between
caregiver training and the turnover of professionals in
RCFEs, considering that team stability is pointed out in the
literature as a factor that positively influences the quality of
care and the safety of residents.24
Conclusion
The present community intervention project, grounded in
the Health Planning methodology and structured by Betty
Neuman's theoretical model, seeks to ensure that the client
system, in this project, the formal caregivers, are able to
maintain the balance of their system, that is, their well-
being. With the aim of achieving this goal, the potential
stress factors that could compromise both the flexible line
of defense and the normal line of defense were identified.
At the same time, the competencies of the formal
caregivers were analyzed with the purpose of empowering
them to provide safe care in RCFEs, focusing the
intervention on primary prevention. In an aging
demographic landscape and with an increasing number of
elderly people living in residential facilities, it is important
that all formal caregivers have the tools necessary to
provide safe care to the elderly. It is therefore important for
the Nurses Specializing in Community and Public Health,
who work with and for the community, to act as an
interlocutor, who can and should assess the needs and
consequent empowerment of formal caregivers, with the
quality and safety of care being the primary objective of
nurses.
The results indicate that the interventions implemented led
to significant improvements in the knowledge and safety
practices of caregivers, especially in the areas of response
to accidents and the cold chain. These improvements
reflect the importance of structured and continuous
empowerment, demonstrating that the qualification of
caregivers not only increases resident safety, but also
contributes to the quality of the services provided.
The execution of this project, with the achievement of the
proposed objectives and the attainment of all the defined
goals, thus enabled continuous improvement in the quality
of care, by empowering formal caregivers, namely in the
area of response to accidents, not only as professionals, but
also as individuals and members of a community.
In summary, this study contributes to community nursing
practice by showing that empowerment of formal
caregivers is an effective strategy for ensuring safety in
RCFEs, addressing an emerging need in societies with
increasingly aging populations. By prioritizing training and
safety, RCFEs can promote not only the well-being of
residents, but also the quality of life and motivation of the
caregivers themselves, aligning with the goals of public
health and the promotion of safe and quality care.
Authorship and Contributions
MG: Conception and design of the study; Collection of data;
Analysis and interpretation of data; Writing of the
manuscript; Final approval of the manuscript and
assumption of responsibility for it.
ES: Conception and design of the study; Analysis and
interpretation of the data; Revision of the manuscript; Final
approval of the manuscript and assumption of responsibility
for it.
AV: Conception and design of the study; Analysis and
interpretation of the data; Revision of the manuscript;
Approval of the final version of the manuscript and
assumption of responsibility for it.
Conflicts of Interest and Funding
No conflicts of interest have been declared by the authors.
Acknowledgments
Nurse Isabel Vilaça (Unidade de Cuidados na Comunidade
Lumiar +, ULS Santa Maria).
Sources of support / Funding
The study was not funded.
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