Clinical Caritas Processes in workshops for caregivers of institutionalized elderly people

Objective: to describe the use of the Clinical Caritas Processes in workshops for caregivers of institutionalized elderly people, aimed at analyzing these professionals’ perception on humane care towards the institutionalized elderly. Method: a convergent care research was conducted with 18 caregivers of a long-term care institution for elderly people in the state of Paraíba, Brazil. Data were collected from June to November 2013, consisting of two months of interaction with the care service and ten meetings conducted in workshops for caregivers. Data were based on the theoretical framework of the Clinical Caritas Processes. Data analysis was based on content analysis and produced ten thematic categories based on the Caritas factors of caring. Conclusion: it was found that the use of the ten Caritas factors of caring were useful for humanistic formations when introducing the group to the conceptions of caring that value the self of the people providing the care and of the ones-being cared for. Descriptors: Nursing; Aging; Nursing Theory; Aged; Care. RESUMO Objetivo: descrever a utilização do Processo Clinical Caritas em ofi cinas para cuidadores de idosos institucionalizados, visando analisar a percepção desses profi ssionais sobre o cuidado humano com a pessoa idosa institucionalizada. Método: pesquisa convergente assistencial realizada com 18 cuidadores de uma instituição de longa permanência para idosos no Estado da Paraíba, Brasil. A coleta de dados foi realizada no período de junho a novembro de 2013, sendo dois meses de convivência com a assistência e dez encontros pautados em ofi cinas para cuidadores, baseados no referencial teórico do Processo Clinical Caritas. A análise dos dados foi ancorada na análise de conteúdo e possibilitou dez categorias temáticas baseadas nos fatores caritativos do cuidar. Conclusão: houve evidências de que a utilização dos dez fatores caritativos do cuidado foi útil na formação humanística quando buscou-se introduzir ao grupo as concepções do cuidado humano que valorizam o self de quem cuida e de quem é cuidado. Descritores: Enfermagem; Envelhecimento; Teorias de Enfermagem; Idosos; Cuidado. RESUMEN Objetivo: describir la utilización del Proceso Clinical Caritas en talleres para cuidadores de ancianos institucionalizados, buscando analizar la percepción de estos profesionales sobre el cuidado humano con el anciano institucionalizado. Método: investigación convergente asistencial realizada con 18 cuidadores de institución de retiro geriátrico del Estado de Paraíba, Brasil. Datos recolectados entre junio y noviembre de 2013, totalizando dos meses de convivencia con la atención y diez encuentros pautados en talleres para cuidadores, fundamentados en el referencial teórico del Proceso Clinical Caritas. Los datos fueron estudiados según análisis de contenidos, surgiendo diez categorías temáticas basadas en los factores caritativos del cuidar. Conclusión: hubo evidencias de que la utilización de los diez factores del cuidado fue útil en la formación humanística cuando se buscó presentar ante el grupo las concepciones del cuidado humano que valorizan el self de quien cuida y de quien es cuidado. Descriptores: Enfermería; Envejecimiento; Teorías de Enfermería; Ancianos; Cuidado. Clinical Caritas Processes in workshops for caregivers of institutionalized elderly people Processo Clinical Caritas em ofi cinas para cuidadores de idosos institucionalizados Proceso Clinical Caritas en talleres para cuidadores de ancianos institucionalizados Fabíola de Araújo Leite Medeiros E-mail: profabiola@bol.com.br CORRESPONDING AUTHOR


INTRODUCTION
Several authors (1)(2)(3) report that the search for long-term care (LTC) institutions for elderly people has increased in recent years because of contemporary changes in the profile of families, an increase in the elderly population of the country, and poor conditions of Brazilian LTC institutions.Studies on the care provided in these institutions is a current need, as is the need for rethinking of the practices and knowledge that determine the conception of aging under a more humane approach.
Among professionals who work at LTC institutions in Brazil, the categories of formal caregivers (those who have received professional education and are hired by healthcare institutions, such as healthcare professionals and caregivers of elderly people) and informal caregivers (family and community) are found.Caregivers are individuals who work with the person to be cared for in a transpersonal mutual relationship (4)(5)(6) .
The group of caregivers for elderly people consists of a selfemployed network that is still not integrated into services, and hence needs guidelines and support from healthcare professionals.The development of scientific studies with caregivers as the main subject is essential so that this occupation is provided with appropriate practices, which bring benefits to the caregiver and the ones being-cared for (7) .
Nursing science provides benefits by clarifying care proposals for diverse healthcare institutions by means of theories.With this understanding in mind, the application of the Theory of Human Caring was chosen as a way to clarify the phenomena of the caring process in LTC institutions for elderly people.The referred theory was created by Jean Watson (4,(8)(9) in the late 1970s, and presents the ten Caritas factors of caring as principles, which are derived from a humanistic perspective combined with scientific knowledge.The focus of this theory is based on the understanding between the interactions of nursing science and care for human beings (the one caring/the one-being cared for).
Transpersonal human care refers to the contact between the subjective worlds of the one-being-cared for and the one caring, a contact that has the potential to go beyond the physical-material or the mental-emotional.It occurs in the relationship between I/you, and through this contact, generates a process that transforms and maximizes the healing process (restoration; caring-healing).It makes use of an attitude of respect for the sacred, which in this case is the other.This being is connected to the universe and to others without divisions of space, time, or nationality and is called Caritas by Watson in her theory developed in 2005.In a developmental context, caring factors initially used in the theory are replaced by elements of the Clinical Caritas Processes (CCP) (4,(8)(9) .
The CCP approach individuals' care with delicacy and sensitivity, giving them special attention.The dynamics of the care process includes a transpersonal dimension between the one caring and the one-being-cared for; in this study focusing on the relationship between caregivers and elderly people.The objective was to describe the use of the Clinical Caritas Processes in workshops for caregivers of institutionalized elderly people.It was aimed at analyzing these professionals' perception of humane care for the institutionalized elderly.

METHOD Ethical aspects
This study was approved by the research ethics committee of the State University of Paraíba.

Type of study
This was a qualitative study with a methodological framework of Convergent Care Research (CCR), anchored under the auspices of four pre-established CCR phases related to the close convergence with the practice of care: conception, instrumentation, examination, and analysis (10) .

Methodological procedures
The research was developed in a long-term care (LTC) philanthropic institution for elderly people established in 1930 (more than 80 years), located in the city of Campina Grande, state of Paraíba, Brazil.Data were collected from June to November 2013, considering as inclusion criteria employees registered at the institution as caregivers for elderly people and other professionals who participated in the care process and wanted to participate in the study (fact to be valued by the Jean Watson's Human Caring Theory, which validates the meaning of self for the caring entity).The exclusion criterion eliminated employees from outside the institution.
Eighteen caregivers of elderly people who were willing to contribute to the study participated in the research.A presentation on the objective of the study was given, and individuals who agreed to participate in the study signed an informed consent form, in compliance with the current legislation.

Research phases
The research was designed according to the following phases: Phase I -Conception: meeting of the key elements involved in the circumscribed care (for caregivers and researcher).At this time, a process of approaching the caregivers was undertaken which was essential so that they knew about the study proposal and could offer suggestions regarding dates, schedules and programming of meetings referred to as workshops (understood as a space for developing and reflecting on practice and theory).Then, the workshops were scheduled according to the observations gathered at the time of the research with the caregivers, and was based on the theory used.
Phase II -Instrumentation: this phase included methodological procedures for the workshops for caregivers of elderly people, based on the ten caring factors of the Clinical Caritas Processes and the group dynamics related to each factor (4,(8)(9) .The workshops comprised theoretical/practical factors consolidated in a program of 40 hours.Relaxation, concentration, interaction sessions with the themes proposed and collective discussions between the caregivers and the researcher were carried out in all meetings.
The workshops were guided by the following questions: 1) Who am I, as a human being and as a caregiver of elderly people?2) Which instruments identify me as a caregiver of elderly people? 3) How do I care for the elderly's hygiene and how do I feel when I am cared for?4) How do I care for the elderly's feeding and how do I feel when I am fed? 5) How do I care for an elderly's change of diapers? 6) How do I care for the environment?7) How do I care for processes of loss and finitude?8) How do I care for communication needs and how do I conduct myself when faced with positive and negative feelings?9) How have I cared for myself?10) How can I innovate the care process?
Phase III -Examination: It was sought to interpret and review the research's purpose before the exchange of theoretical and practical knowledge.A cross-sectional relation among knowledge involving spiritual-philosophical listening and the scientific method is recommended in the CCR (10) .
Phase IV-Analysis: it was observed that in the CCR, the situation of the study could be planned, but it did not necessarily remain steady during the whole period (10) .The workshops, their records, and descriptions in the field diary generated a lot of information that needed a systematic apprehension, synthesis, theorizing and recontextualization.At the end of each workshop, it was necessary to organize all content gathered for further thematic analysis by category.
For analysis of the potential use of the Clinical Caritas Processes by caregivers, a self-evaluation instrument was applied based on Watson's study at the end of all the workshops (8) .

Data analysis
The data collected were transcribed in full and submitted to thematic content analysis.The following thematic categories were identified based on the ten Caritas factors of caring: 1) Caregivers practice love, kindness, and equanimity; 2) Caregivers describe their authenticity with their working tools; 3) Caregivers try to cultivate care practices with self-consciousness for themselves and others; 4) Caregivers develop a trusting relationship in transpersonal caring; 5) Perception of caregivers towards elderly people regarding positive and negative feelings; 6) Caregivers use creativity and knowledge to learn how to be, how to do, how to understand, and how to interact; 7) Engagement of caregivers in genuine teaching-learning experience; 8) Caregivers try to provide a caring environment for the institutionalized elderly; 9) Caregivers assist with basic needs with the intention of caring; 10) Perceptions of caregivers and of elderly people about the mysteries of life and death.These categories are demonstrated in Box 1.
The content of the analyzed statements was catalogued with the letter C (caregiver), and listed according to the cataloguing of researchers in a meticulous organization of the analyzed data.Caring trees.
Objective: definition of self-image as a caregiver of elderly people.
2 Instillation of faith and hope.Caregivers describe their authenticity with their working tools.
Working tools.
Objective: to identify objects related to the performance of care in the institution*.
3 Cultivation of sensitivity to oneself and others.
Caregivers try to cultivate care practices with self-consciousness for themselves and others.
Workshop in care regarding bathing, feeding and changing diapers.
Objective: to identify the feelings which arise when taking care of others and being cared for.

4
Development of a helpingtrusting (human caring) relationship.
Caregivers develop a helpingtrusting relationship in transpersonal caring.
Workshop on bed bath.
Objective: to reflect on diverse situations experienced in the institution that develop confidence between caregivers and the elderly.

5
Promotion and acceptance of the expression of positive and negative feelings.
Perception by caregivers of elderly people regarding positive and negative feelings.

Flowers and feelings.
Objective: to reflect on positive and negative feelings involved in the care relationship with the institutionalized elderly.
6 Systematic use of creative problem-solving in the caring process.
Caregivers using creativity and knowledge to learn to be, how to do, how to understand, and how to interact.
Ulcers: how to deal with them?
Objective: to identify different types of injuries in the elderly like pressure ulcers, and to describe caregivers' actions concerning them.
To be continued

RESULTS
The analyzed data were organized according to the ten thematic categories related and adapted to the Clinical Caritas Processes.

Category 1: Caregivers practice love and kindness
In this workshop, pictures of 40 different types of trees were arranged on a mat, accompanied by the sound of instrumental music.Caregivers were asked to choose the tree that they felt more identified with in their work with the institutionalized elderly.There were poetic reports regarding the choices, which determined the thematic evaluation by means of the repetition of semantics in the Portuguese language such as: nouns associated with kindness, affection, and dedication; verbs that validated giving and generosity (to transmit, to give, to know, to embellish); and adjectives associated with important human values such as happy, wonderful, beautiful, and loving.
Most of the time, caregivers expressed satisfaction for their work with elderly people, perceiving themselves as key elements in the transpersonal caring relationship with the people living in the institution.
There was an understanding of the caring factors that were incorporated in the creative use of knowledge as part of the caring process; in the engagement and the genuine experience of the exchanges among beings (the one caring and the onebeing-cared for); in the importance of the caring environment (involving the physical and non-physical), and in the existential dimensions in the life of the person who was being cared for (8) .
Caregivers' work with the elderly goes beyond the performance of daily tasks, extending to moments of spiritual and human exchange, and knowledge associated with the caring/healing process.Although marked by difficult times that involve a lot of work, stress, and small compensation, the interaction in the institution is also stimulated by human understanding and the search for the subjective world of those involved in care as a profession.
Category 2: Caregivers describe their authenticity with their working tools All objects found necessary for the caregivers' routine in the institution where the present study was conducted, were arranged on a mat.Objects such as: flower, cologne, eyeglasses, coat, clothes, geriatric diaper, comb, nail case, shaver, book, rosary, Bible, a pearl necklace, hat, shawl, pair of sandals, medicine case, syringe, soaps, laundry detergent, plate and spoon, potty, sheet, towel, a suitcase, cane.With the sound of instrumental music in the background and guided relaxation, the participants were told to look closely at the objects.While observing the objects, they were asked to choose those that were more directed to the dynamics of their work, by means of the following question to the caring-trees: which objects do you think could best symbolize your care for the elderly who live here?There were several choices, withdrawals, exchanges and doubts.The objects were picked up and returned.Some said that they would choose some of the objects that were already chosen by others.In an atmosphere of joy, availability, and relaxation, they talked to each other about the objects and their identification with them.Some agreed and others disagreed with each other.When they reported being satisfied with their choices, all caregivers shared their authenticity, explaining their occupational identity with the object(s) chosen.
After content analysis for a group of caregivers, the tools that most identified their performance were those with direct association with physical body care: diaper, laundry detergent, clothes, cologne, soaps, plate, etc.Therefore, a thematic subcategory could be created.It was, "Identification of care Caring in a healing environment.
Objective: to reflect on ways that caregivers find ensure comfort and improvements in the environment.9 Assistance with gratification of human needs.
Caregivers assist with basic needs with the intention of caring and honoring their oneness with the institutionalized elderly.
Caring for oneself.
Objective: to reflect on the need for caring for oneself so as to be able to care for others.Statements of caregivers who chose such objects showed that care practices with the bodies of the elderly were related to practices of hygiene that demanded strength, dedication, and detachment of caregivers in order to perform at their best.Practical experience of these workers was necessary, especially when the elderly presented functional disability and decline associated with disabling chronic illnesses, such as stroke and dementia.
Another thematic category was associated with the "Identification of the care tools that are related to body-spirit".In this category, some caregivers picked up objects associated with body and soul care.When picking up a Bible for example, they reported that the reading calmed residents' tensions.Other objects available that referred to the subjectivity of caring were the rosary, coats, moisturizing creams and oils, and the radio.These were mentioned as facilitators that dealt with feelings of sadness, abandonment, and loneliness shared by the elderly with the caregivers in the institution.
The connection with the people being cared for requires authenticity and a focus on the relationship with others and their beliefs, This authenticity is supported by the deep subjective experiences in an individual.Maintenance of faith, respect for others belief, and encouragement of hope in some vital processes regarding health or illness are essential elements in the act of connecting with others (8,11) .
Category 3: Caregivers try to cultivate care practices with self-consciousness for themselves and others In the third workshop, two care performances were simulated, one without dialogue and another with dialogue.The participant caregivers were asked to impersonate an elderly person completely dependent on caregivers, so that they were fed blindfolded and had their diapers changed.The first situation was performed without dialogue, and the second was based on a verbal explanation of such care followed by the reflection: how have I cared for the elderly?
Caregivers mentioned difficulties regarding staff shortage and need for technical training to deal with disabling chronic illnesses and mental disorders.
In this workshop, caregivers recognized the need for cultivating self-consciousness in their practice, and attempting to understand the meaning of autonomy and the self-esteem of the ones-being-cared for, in this case, the institutionalized elderly.Recognizing the self-determination and autonomy of the elderly in spite of their functional dependence on caregivers for performing activities of daily living are essential aspects for the cultivation of sensitivity to oneself and to others.

Category 4: Caregivers develop and try to foster helpingtrusting relationship in transpersonal caring
In this workshop, cultivation of sensitivity in the practice of care by caregivers was mentioned.They were asked to write about the bathing time of the elderly in the routine of the institution.In the analysis shared by one of the participants, the importance of therapeutic touch and building trust for caregivers stand out:

Every time I give bath, I try to instill confidence, because elderly people always need respect, especially when their bodies are exposed, without clothes, in a room where others are talking, and imagine if the elderly is confined in bed, with physical and visual deficiency, but conscious. Oh, it is difficult! It is very difficult! Much confidence is required, otherwise, we cannot do anything, and they are the most affected. (C.5)
In the abovementioned statement, it is worth noting the complexity and subjectivity felt by this caregiver when describing difficulties in providing care to an elderly person with a high degree of vulnerability.Elderly person are abandoned because of several social factors.They often have disabling illnesses, and need dignity and respect in collaborative caring actions in the maintenance of their remaining life.This confirms the importance of rethinking the role of these caregivers in the face of situations of high human complexity and which involve decision making on the quality and dignity of the person.
Category 5: Perception of caregivers of elderly people regarding positive and negative feelings A workshop, was carried out in a group which was called 'flowers and feelings'.Eighteen molds of paper flowers (cut out and folded) and a basin with water were distributed to the 18 participants.Accompanied by the sound of instrumental music, all participants were asked to throw their molds in the water, which caused the blossoming of the flower, and they were asked to write down their feelings (good or bad), and then reflect on them.
In the content analysis of all statements, the following negative reports were found: presence of constant physical fatigue regarding the work in the institution; stress of caregivers with overwork; low compensation for the occupation of caregiver; and concerns regarding the feelings of the institutionalized elderly for the caregivers themselves -sometimes the elderly showed repulsion towards the caregivers.The caregivers found that part of the reason for this repulsion was because the choice of being institutionalized was not a decision made by the elderly, but resulted from negative circumstances that led them to that institution.Therefore, the transpersonal caring relationship is many times affected by life stories of each elderly resident.
As to the feelings analyzed in this workshop as positive, the caregivers mentioned that providing care to the elderly in the institution generates the self-perception that they were kind human beings.This increased their love for others who were abandoned and caused feelings of inner fulfilment in the caregivers.
In the workshop, there was a recognition of the need for acknowledging that LTC institutions are homes, and not warehouses for abandoned and dependent elderly people (nursing homes), and on the need for the fulfilment of statutes that ensure the elderly's dignity.These depend on the restructuring of these institutions and the breaking of paradigms in the promotion of the quality of life for those who need them in their old age.

Category 6: Caregivers using creativity
To analyze the caring factor focused on creativity in the institution, one of the workshops was directed toward caregivers' knowledge regarding pressure ulcers and how they perceived any difference in an elderly's skin.From a rational understanding of the problem, the following statements were selected, which showed formal and unanimous thoughts about ulcers in the elderly: If we do not notice modifications in the skin of the elderly who is confined in bed or is a wheelchair user, the wound will soon appear and gradually deepen.Therefore, we do not let their skin turn red, nor the elderly to be soiled in the bed; otherwise, ulcers will appear and make them suffer, thus increasing work and making everything more difficult.Pressure ulcers may lead an elderly to death.(C.6)Therefore, although in their daily dynamics, these professionals had knowledge about decisions and actions regarding aid to the elderly in activities of daily living, there was a need for further knowledge focused on the technical training of caregivers for their care practices in the institution and observation of abnormalities together with the health team of the institution.Regarding the creative use of individual techniques of care, some mentioned that sometimes, massages, talking and being close to the elders were the main forms of relaxation and led to the preservation of the care relationship at the institution.

Category 7: Engagement of caregivers in genuine teachinglearning experiences that involve the institutionalized elderly
The dynamics of matchstick and matchsticks bundle were carried out.A single matchstick breaks easily, but not when they are in a set.In the face of this and other reflections on the origin of caregivers' knowledge, it was possible to identify which part of the knowledge is experienced in the interaction among caregivers, elderly people, and healthcare professionals of the institution, such as nurses and doctors.
The caregivers reported that part of their knowledge came from practice, but that it was very important that the institution's management offer incentives for professional training such as courses for caregivers, because they recognized their need for more technical-professional knowledge.This was one of the ways that the caregivers realized would help them in teaching-learning and in the relationship with the resident elderly, which is evidenced by the following statement: These workshops helped us.We learned with each other, we also knew more about the technique, because with knowledge that we acquired in the school of life and with classes like these, we may be increasingly better in working with the elderly; it is too much, and we must know how to make it properly.(C.8) Dealing with the social requirements that favor caregivers' training requires awareness and understanding of teachinglearning in care practice together with a humane approach regarding the aging process.
Category 8: Caregivers try to provide, with the available resources, a caring environment to the institutionalized elderly In the meeting room, during the workshop on healing environment, an environment of relaxation was created with soft colors, ambient music, incense, clean sensation, mattresses, and the participants were taught massage techniques to apply in each other.It was possible to reflect on the meaning of the environment for the performance of caring, and the fact that the healing environment must be welcoming and comfortable was a unanimous feeling.
Transforming the environment into a pleasant, clean and comfortable place induces a general improvement in aesthetics and adds a professional touch.Nonetheless, no matter how the external environment is set up, the internal environment is the most arduous, requiring professional performance.It is necessary to recognize oneself as human being, a beingin-the-world, and this requires the essence of the human being.Therefore, in spaces of care, it is important to interweave complex multidimensional, dialogic, and ecosystem understandings that involve interaction among different areas in the search for solutions (especially the care in LTC institutions), and that can handle changes in paradigms and practices.
The LTC institution where the present study was conducted, showed that belongings were shared and individual use was restricted to beds and furniture.In other words, it seemed that when choosing a LTC institution, many times, the elderly lose their history, identity and privacy in making choices.Caregivers, directors, and researchers must also reflect on the importance of not losing the individuality of the elderly person in spite of the need for being in an institution.The content the statement below confirms the search for this dignity: For the environment, it is necessary to think about privacy.There is not much privacy here, and this bothers me as a caregiver.(C.9) Category 9: Caregivers assist with basic needs It was realized that both the institutionalized elderly and caregivers need care.One of the ways to gratify human needs in others is to understand the human needs of every one.In this aspect, a workshop with the following question was conducted: How have I perceived myself as a human being and caregiver of the elderly?
In their statements, caregivers showed that they also need care.In dialogic discussion in the workshop, it was mentioned that caregivers also need care, so that the quality of care provided by them is satisfactory.Understanding that caregivers are key elements in the care process for the institutionalized elderly, it would be necessary to implement programs focused also on caregivers, so that in addition to technical training, projects of the maintenance and promotion of their own health condition are implemented.Initiatives such as identification of secondary caregivers to support activities, possibilities of establishing statutes that ensure more time so that they can care for their health, and the creation of caregiver groups with opportunities for discussions on the difficulties and strategies of care are viable suggestions for rethinking their needs so that the caregivers can perform better.
Physical wear and displeasure with life because of sacrifices for the profession were referred to by the institution's caregivers.There is need for viewing caregiving as a self-employed occupation that requires social attention, especially considering population demand, an expansion in provision of their services, as well as ensuring quality of services for the population who needs them.Providing caregiving in institutions requires the need for reflection and for further studies focused on the image of caregivers who work in these institutions.
Category 10: Perception of caregivers of elderly people's attitudes about the mysteries of life and death When caring for others or allowing to be cared by others in difficult conditions in life, human beings face situations that at times give rise to feelings related to existential doubts that maximize thoughts about existing.
Based on this conception, there were suggestions during the workshops on how to provide care in the face of the finitude of life.In the institution, death is a cruel certainty seen and felt by those who live there, especially because the residence did not consider every one's privacy.The resident elderly is exposed to continuous situations of suffering and loss that are felt more deeply because of their own age, and frightens those who are most lucid when witnessing such departures.This was said and felt by some caregivers: It is not easy to deal with death, especially in a place like this, where there is much sadness, abandonment, not by us, but abandonment of life histories.The elderly who are abandoned by their families and come here, die long before entering here.They do not tolerate us, nor the institution.They are rebellious people.Then, we try to understand what they feel.This is it.It is Some of them are able to like us, others not.Because they wanted to be with their family and not here with us.They thus surrender to sadness, and it becomes very difficult to provide care.When we are able to provide some care to one of these, it is rewarding for us.It is as if we could achieve a challenge.(C.7)   This statement illustrates the challenges in the adaptation process to the new life of the institution by the elderly who did not choose to be there, but were placed there because of several reasons.This fact determines their attitudes of refusal to live and of an anticipated death in the face of the sorrows of their existence.A study (12) corroborates the statements made above which affirms real situations of abandonment of elderly people by their families in the institutions, which leads to a new rethink of this rapprochement.
There is a need for reflecting on death in the form of the question, 'what does it carry with it?'Understanding that death goes beyond the natural and biological phenomenon of existence induces cultural, social, spiritual and human reflection.These reflections impose on professionals, especially in healthcare, the need to act differently when confronted with the dying, the abandoned and human beings who are unconscious of their own situation or identity.
At the end of all the workshops, there was a self-evaluation that favored the analysis of the whole process of knowledge exchange, an evaluation of the potential of application of the workshop results, and discussions with use of the CCP.
After the workshops, caregivers of elderly people who already make use of care practices within an empirical process of work, considered themselves essential tools for those they cared for in the institution.
Understanding the care process in a LTC institution goes beyond the old perception of nursing homes as places where elderly people were abandoned, orphans of their families and society.It also makes possible the understanding of the urgent need for locating studies on LTC institutions.These studies would provide alternatives that could contribute to a change in paradigms that have been negatively passed on throughout the history of these institutions and that, in some way, stereotype these important spaces for human care (1,6,12) .
The change in paradigms arises from the reasoning that LTC institutions should not be seen as places that host elderly people who are rejected and abandoned by their families, but a choice made by each individual.Therefore, necessary improvements must be undertaken so that there is a continuity to the proposals that provide decent housing without prejudice and stereotyping.These proposals must be included in the public policies of developing countries (12) .
To achieve this objective, all necessary knowledge must be sought, especially regarding the understanding of how care is provided in LTC institutions and how to collaborate in the development of public policies and programs that support this underserved area of Brazilian society.
The use of the CCP (4,(8)(9) made possible its implementation by caregivers of elderly people in an institution, promoting reflection on the quality of care provided, and an understanding of the real essence of what the caregivers already do for the elderly, and how they can improve their performance.
Measurement of care mentioned in some international studies makes use of the CCP theoretical resources.Making use of the ethics of human values in its initial proposal, it ensures the recognition of the ten Caritas factors of caring that should be present in professionals searching for the improvement of the vital process of caring for the elderly (8)(9) .

FINAL CONSIDERATIONS
The present study made possible a deep analysis of the perspective of caregivers of elderly people and on how they perceive themselves as participants of the care process in a LTC institution.In the workshops, the following statement was evident: caregiving underscores the human responsibility that is involved when dealing with the institutionalized elderly.
Regarding the use of the ten Caritas factors of caring, it was possible to measure the importance of care provided by the institution's caregiving team.The study showed the need for a return to a humanistic approach; for improvements in care for the elderly; for important reflections on care provided by the institution; and for the need for interaction between institutionalized care and a greater participation of the residents' families.
This study contributed to studies that involve the science of nursing, considering that it was based on the Clinical Caritas Processes in an institutional environment.Further studies on the subject in other regions of the country is suggested to address different realities and evaluate more concise caring principles in LTC institutions.The care discussed in workshops by institutional caregivers was considered relevant.Convergent care research was used, which enabled the interaction between researchers and participants in caring for elderly people.
In conclusion, the use of CCP was of extreme importance for the orientation of care workshops, because it enabled the creation of thematic categories and self-evaluation of the ten Caritas factors of caring.Another prominent point was the empowerment of caregivers concerning their daily practice in the institution with the elderly.The workshops based on the CCP optimized the abilities of all participants regarding their work, making possible more human care.Finally, it is worth mentioning the use of the Convergent Care Research as an essential method in the undertaking of studies like this, where care for the human being is based on the knowledge that is developed.

Box 1 -
Thematic categorization based on the Clinical Caritas Processes applied to caregivers of elderly people in training workshops, Campina Grande, Paraíba, Brazil, 2013 The ten Caritas factors Clinical Caritas Processes by caregivers of elderly people Workshop name/objectives 1 Formation of humanisticaltruistic system of values Caregivers practice love and kindness.
Clinical Caritas Processes in workshops for caregivers of institutionalized elderly people tools that are directly related to the body".At this time, all statements related to the use of objects associated with body care were recorded, such as perfumes, soap, eyeglasses, cane, potty, sandal, clothes, handkerchiefs, diaper, and comb.
Note: The objects were based on the first phase of the Convergent Care Research, when the relationship of care was experienced in the institution.The selected objects most used in the long-term care institution for elderly people were: flower, cologne, eyeglasses, coat, clothes, geriatric diaper, comb, nail case, shaver, book, rosary, Bible, a pearl necklace, hat, shawl, pair of sandals, medicine case, syringe, soaps, laundry detergent, plate and spoon, potty, sheet, towel, a suitcase, cane.Rev Bras Enferm[Internet].2016 nov-dec;69(6):997-1004.