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INTRODUCTION
The demographic changes observed in recent years, together with the forecast that the number of elderly people for every 100 young people, will double by the year 2080, from 147 to 317, adds to concerns at various levels. The average life expectancy at birth will be 80.62 years, so the inversion of the age pyramid is expected (1).
Despite the fact that people live longer, the elderly, due to the aging process itself, such as the impairment of neuromuscular performance, evidenced by weakness or loss of muscle strength, slowing of movements, decreased balance, mobility and involuntary weight loss(2), as well, with the appearance of debilitating chronic diseases, loss of the quality of life, which makes them vulnerable and very fragile (3). Despite aging progressing at a variable speed from person to person, in general, the decline begins during the third decade of life, and increases substantially from the age of 60 onwards (4).
Physical exercise, cognitive training, and social integration, through the implementation of group intervention programs, have been shown to be effective in reducing the elderly's frailty indicators (3). Therefore, this fragility can also be reflected in the lack of autonomy, as is defined in the analysis of the concept (5).
Autonomy is a multidimensional concept that includes attributes such as: cognitive state, emotional intelligence or emotional management, social integration, intellectual condition and physical condition, being essential the existence of homeostasis among these attributes to consummate an independent life (5).
Due to the importance of maintaining autonomy for the quality of life of the elderly, nurses and especially nurse specialists, should analyze their role in this context, as these, due to their functions and proximity to the people targeted for care, play a crucial role in promoting people's autonomy, particularly in the elderly (6). Thus, it is expected that in the relationship between health professionals, including nurses and specialist nurses, there is a basic principle of respect for autonomy.
All nurses have a duty to promote people's autonomy, regardless of their specialization, as this concept is part of the common competences according to the common competencies of general care nurses (7). According to the Portuguese Nurses Order (7:4745), common competencies "are the competencies shared by all specialist nurses, regardless of their area of specialty, demonstrated through their high capacity for conceiving, managing and supervising care, and also through effective support for the professional practice specialized in training, research and consulting".
Nursing care is considered and systematized through the implementation of the nursing process. Where the nurse identifies the nursing diagnoses, which are the real or potential problems of the people, prescribes, implements, and evaluates nursing interventions, which respond to the needs of the people for whom they care, which in this scope concern those who promote the autonomy of the elderly (8).
In times of pandemic, in which freedom is called into question, people are limited to a space, thus appearing physical limitations, social isolation, lack of cognitive stimulation, due to the need to reduce contacts, the principle of non-maleficence is questioned (9). In addition to these facts, it isn't easy to communicate due to personal protective equipment. This is so necessary in these pandemic times, even when it is possible to do so. As is recognized, communication is a fundamental tool, if not the only one, in establishing a therapeutic relationship being very important in the provision of nursing care (10). Thus, nurses, in addition to the challenges described above, will also have to reinvent themselves, at this time, to respond to the needs within the scope of autonomy (11).
Certain of the importance of the theme, this investigation aims to answer the following question: How is the care provided by specialist nurses in rehabilitation different from other specialist nurses, concerning the self-assessment of promoting the autonomy of the elderly?.
The present study aims to: identify and compare the perception of rehabilitation nursing specialists and other specialist nurses on the development of interventions that promote the autonomy of the elderly. Testing the hypothesis: There are differences in the self-assessment of promoting the autonomy of the elderly among nurse specialists in rehabilitation nursing and nurse specialists in other specialties.
METHODOLOGY
The study is characterized as a descriptive-correlational and transversal, quantitative, and non-probabilistic snowball sampling. The link created on the Google Forms® online platform was sent via email to nurses from the contact list of all researchers, requiring these same nurses to share with other nurses, with the same characteristics, and fill out the questionnaire.
The sample consisted of 143 nurses who met the following inclusion criteria: 1) being a nurse specialist; 2) work with the elderly; and 3) work in the community or work in inpatient institutions.
The study was approved by the Ethics Committee of two health institutions in the northern region of Portugal (Opinions No. 324/17 and No. 11/18), before data collection. All participants were informed of the study and its objectives and the fact that all data provided would be treated anonymously, thus ensuring confidentiality and anonymity. Participants could only start answering the questionnaire, after confirming they read and understood the informed consent, accepting to participate in the study.
The instrument was applied during September and October 2020.
It should be noted that the present study was carried out during the pandemic period, since in Portugal, the first case appeared in March 2020, and data collection was carried out in the period from September to October 2020, when the second wave of COVID-19 was imminent.
The data collection instrument included the participants' sociodemographic and professional data containing the following information: age, sex, service time, if they have a specialty, what is the area of specialization, service time as a specialist, and also the "Self-Assessment Scale of Promotion of the Autonomy of the Elderly (EAPAI)" (12) to self-assess how they promote the autonomy of the elderly.
The "Self-Assessment Scale for the Promotion of the Autonomy of the Elderly" is a valid instrument for the Portuguese population, by Limaet al.(12), composed of 68 items organized into 6 factors. Factor 1) is called the development of emotional, social and self-care interventions (with 19 items); factor 2) is called the development of physical and cognitive interventions (with 9 items); factor 3) the development of interventions for instrumental activities of daily living (with 13 items); factor 4) the development of evaluative interventions in the area of self-care (with 12 items); factor 5) the development of evaluative interventions in the emotional, cognitive and social areas (with 7 items) and factor 6) for caregiver training (with 8 items), with a Cronbach's alpha of 0.98. Items are assessed using a Likert-type response - allowing positioning in a continuum of variation in self-perception: 0) I do not apply; 1) I apply a few times; 2) I apply frequently; 3); I apply many times; 4) I always apply. The lowest self-perception scores are attributed to a negative self-assessment of how nurses promote autonomy for the elderly (12). Thus, the higher the score, the better the perception of promoting the autonomy of the elderly.
For the statistical treatment of data, IBM SPSS® version 26 was used. Descriptive and inferential statistics were used for data analysis, the 95% confidence interval was adopted, with a p-value <0.05 to assume the hypothesis that there were differences between the studied variables.
In the descriptive analysis, nominal and ordinal variables were analyzed for frequencies and percentages, while scalar variables were analyzed for means and standard deviation.
RESULTS
The study included 151 Portuguese nurses. The sociodemographic characteristics of the participants are shown in table 1.
The average age of the participants was 40.3 years (SD = 7.77) and 122 (80.8%) were female. Most of the participants 72 (47.7%) were nurse specialists in rehabilitation nursing. On average, the group of participants had been working for 17.59 years (SD = 8.77). As specialist nurses, they performed functions in this category, on average for 8.07 years (SD = 6.67), and 102 (67.5 %) nurses worked in inpatient institutions, and 49 (32.5) worked in the community.
Table 1: Socio-demographic and professional characteristics of the study sample (n = 151)
| Variables | n | % | 𝐱̅ | SD | Min | Max |
|---|---|---|---|---|---|---|
| Sex: Feminine Male |
122 29 |
80,8 19,2 |
||||
| Age (years): | 40,34 | 7,77 | 27 | 62 | ||
| Speciality: Rehabilitation nursing Community nursing Medical-surgical nursing Mental health nursing and psychiatry Child health nursing and paediatrics Maternal and midwifery nursing |
72 22 33 16 2 6 |
47,7 14,6 21,9 10,6 1,3 4,0 |
||||
| Service time (years): | 17,59 | 7,41 | 4 | 37 | ||
| Length of service as a specialist (years): | 8,07 | 6,67 | 0 | 32 | ||
| Place where they work: In inpatient institutions In the community |
102 49 |
67,5 32,5 |
Regarding the self-assessment of the promotion of autonomy perceived by specialist nurses, considering that 0 means that it does not promote and 4, they always promote, for all factors of the EAPAI scale, specialist nurses, in general, perceived that they promote the autonomy of the elderly.
The specialist nurses demonstrated that the development of interventions for instrumental activities of daily living (factor 3), is the factor in which, on average, they invest the least in their clinical practice. This is followed by the development of evaluative interventions in the emotional, cognitive and social areas (factor 5) and emotional, social, and self-care interventions (factor 1), as shown in table 2.
Table 2: Descriptive statistics of EAPAI factors for specialist nurses (n = 151)
| Scale factors | Specialist nurses | |
|---|---|---|
| 𝐱̅ | SD | |
| Fator 1 - development of emotional, social and self-care interventions | 3,19 | 0,76 |
| Fator 2 - development of physical and cognitive interventions | 2,44 | 1,19 |
| Fator 3 - development of interventions for instrumental activities of daily living | 1,69 | 1,04 |
| Fator 4 - development of evaluative interventions in the area of self-care | 2,55 | 0,95 |
| Fator 5 - development of emotional, cognitive and social evaluative interventions | 3,25 | 0,99 |
| Fator 6 - caregiver training | 2,78 | 1,11 |
| Total EAPAI | 2,65 | 0,76 |
In the inferential analysis between the rehabilitation nursing specialty and the other specialties, there are statistically significant differences between the rehabilitation specialty and the other specialties regarding the development of physical and cognitive interventions (factor 2) and the total EAPAI scale. Thus, regarding the self-assessment of elderly autonomy promotion, rehabilitation nursing specialists perceive to promote more autonomy for the elderly, with a statistically significant difference for both factor 2 (t = - 4.92; gf = 145, 7; p <0.001), as for the total EAPAI (t = - 2.02; gf = 146.4; p <0.05), as shown in table 3.
Table 3: Description of factors by rehabilitation speciality or other nursing specialists (n = 151)
| Scale factors | Other nursing specialists | Rehabilitation Nursing Specialists | p | ||
|---|---|---|---|---|---|
| 𝐱̅ | SD | 𝐱̅ | SD | ||
| Fator 1 | 3,08 | 0,80 | 3,32 | 0,69 | 0,057 |
| Fator 2 | 2,03 | 1,22 | 2,90 | 0,96 | <0,001 |
| Fator 3 | 1,66 | 1,12 | 1,71 | 0,95 | 0,770 |
| Fator 4 | 2,57 | 1,00 | 2,52 | 0,89 | 0,738 |
| Fator 5 | 3,10 | 1,12 | 3,41 | 0,79 | 0,054 |
| Fator 6 | 2,66 | 1,16 | 2,92 | 1,05 | 0,144 |
| Total EAPAI | 2,53 | 0,83 | 2,78 | 0,66 | 0,048 |
DISCUSSION
In the day-to-day provision of nursing care, the professional is faced with a variety of situations that deserve their full attention, so there is a need to use the best available evidence through conceptualization and development of competencies.
Throughout the life cycle, the person experiences transition processes between health and illness. Nurses, through their care, satisfy the needs resulting from this change, facilitating the processes of reintegration into the new situation successfully.
The sociodemographic and professional data in the sample are in line with the data from the Portuguese Nurses Order (13). In which the majority of nurse specialists in Portugal are female, the age groups that comprise the most significant number of nurses are between 31 and 35 years of age and 36 to 40 years of age, with 13607 and 13164 nurses, respectively. Rehabilitation nursing is the specialty with the largest number of specialists, and the sector with the most significant number of nurses is inpatient institutions. Although there seem to be convergences between the sample and the data available in the present sample, it was not intended to obtain its representativeness, so it is not guaranteed.
As highlighted by Baratieri and Sangaleti (14), nurses face difficulties in promoting the person's autonomy due to the demands on behalf of the services, namely due to the gap between the nurse-patient ratio or the lack of the managers' sensitivity towards this issue, corroborating in part the results of the present study, in which it is shown that nurse specialists, despite promoting the autonomy of the elderly, still neglect the development of interventions within the scope of instrumental activities of daily living. This event is probably due to the lack of working conditions, commonly highlighted by health professionals, in their contexts.
Concerning the scale factor that nurse specialists perceive to promote more, it is the development of evaluative interventions in the emotional, cognitive and social areas, corroborating the results of Passos, Sequeira and Fernandes (15), which identified the related nursing foci with mental health more common in older people and concluded that most users had cognitive impairment, depression, anxiety, being necessary to identify these foci, evaluative interventions.
The concept of autonomy is multidimensional, covering dimensions such as: physical capacity, cognitive capacity, social integration and emotional intelligence (5). Therefore, in this context, EAPAI allows nurses to self-assess how they work to promote the autonomy of the elderly in their care provision, namely through the identification of problems or potential problems and the respective nursing interventions, allowing them to adapt their responses to the needs of the caregivers (12).
The lack of promotion of the autonomy of the elderly person is particularly important, as they, due to the processes resulting from aging, may see their autonomy lost abruptly and often without returning to the previous state. Thus, the prevention of phenomena that disturb this homeostasis of the processes covered by autonomy should focus on nurses' attention, especially nurse specialists, as the authors point out (7, 8).
It is necessary to optimize the responses to the person and their family, regarding promoting the autonomy of the elderly, in a comprehensive logic, covering all domains of autonomy. Since it is necessary to identify the weaknesses to open doors to the implementation of effective intervention projects, promote research, facilitate the implementation of equitable and inclusive political measures (16), as is presented by the results of the present study.
Regarding the self-assessment of the promotion of the autonomy of the elderly, through the application of the EAPAI, there are still no studies, since it is a recent instrument.
Nurse specialists perceive to promote the autonomy of the elderly, with less attention to the development of interventions for instrumental activities of daily living. Therefore, these data partially corroborate the study by Cruz, Gomes and Parreira (17), in which they concluded that nurses give priority to foci and interventions aimed at satisfying self-care.
The hypothesis is confirmed concerning the differences in the self-assessment of promoting the autonomy of the elderly between nurse specialists in rehabilitation nursing and other nurse specialists. Thus, it is concluded that nurses specialized in rehabilitation nursing perceive more promotion of the autonomy of the elderly, in reference to the total scale and in particular to the development of physical and cognitive interventions, corroborating these results, which demonstrates the scientific evidence (6 , 18, 19), since these, through their results, state that rehabilitation programs promote not only physical skills, but cognitive skills.
Nurses who specialize in rehabilitation nursing, according to their competencies, design, implement, monitor, and evaluate rehabilitation programs, which aim to minimize the impact of installed disabilities, at the neurological, respiratory, and orthopedic levels, among other disabilities, planning care aiming towards the reintegration into the family and community, providing them with the right to dignity and quality of life (20), thus promoting the condition of autonomy, as can be seen in the results of the present study.
The present study results corroborate the study by Matos and Simões (21), where they highlight that the nurse specialist in rehabilitation, as part of the multidisciplinary team, promotes skills in the area ofcommunication, negotiation, clinical interview. Also, it obtains in-depth knowledge about accessibility, analyzes and prescribes support products, facilitates and promotes the use of resources available in the community, which facilitates social reintegration.
Matos and Simões (21) emphasize that functional motor reeducation programs must integrate the psychological, cognitive and physical dimension, providing part of the answer to the needs in the scope of promoting autonomy, since this also involves social integration, which is also addressed in a subtle way by the authors, when they talk about the person's preparation for returning home and the caregiver's preparation to take care of the person.
Thus, even in a pandemic phase, nurse specialists perceive that they promote the autonomy of the elderly, despite the challenges they face, due to the pandemic caused by SARS-CoV-2, which limits care, not only due to the number of precautions needed to prevent the spread of the disease, but also by restricting freedom. This lack of freedom arises in work contexts, in carrying out movements, within health units and in the community, due to the limitations that disease prevention imposes on us. However, this pandemic leads us to consider other aspects that, due to necessity, have been claimed, such as solidarity, empathy, understanding, the importance of affective relationships, emotional well-being, the way in which people integrate society, particularly the elderly and the respect for their autonomy (22), as is evidenced by the results of the present study.
These results allow us to infer that the intervention of nurse specialist nurse in rehabilitation nursing, brings gains in promoting the autonomy of the elderly. Although this study does not evaluate the effective health gains of the elderly, however, through the self-assessment of the dimensions that respond to the autonomy of the elderly person, it is clear that these professionals promote it through the care they implement.
This self-assessment allows the identification of the dimensions that promote the autonomy of the elderly, nurses, namely nurse specialists, already promote autonomy and the dimensions they should invest in if they do not eventually do so. Thus, this self-assessment alerts not only the need to improve the provision of care, in this context, through continuous training, but it also alerts to the lack of working conditions and the need to implement measures to rectify practices. This type of instrument in teaching is already a current practice, and its implementation in health care practice is equally important (23).
Like other studies, the present study has limitations, one of them being that the sample is small, not allowing the generalization of the results. Another potential limitation can be attributed to the fact that it is a recent scale and has not been tested suficiently. This study will thus contribute to add more evidence about it. Future research should be carried out, seeking to use the same instrument in a larger sample of nurses.
CONCLUSION
The present study intended to respond to the objective of identifying and comparing the perception of nurses who are specialists in rehabilitation nursing and nurses who are specialists in other specialty areas. It was found that the majority of specialist nurses perceived to promote the autonomy of the elderly. However, there are differences in perception between specialist nurses in rehabilitation nursing and other specialist nurses, especially in terms of the scale factors related to the development of physical and cognitive interventions, confirming the formulated hypothesis. Thus, there is a need to hire more specialist nurses in rehabilitation nursing.
The role of nurse specialists in rehabilitation nursing is notorious, as they develop nursing interventions that promote skills: physical, cognitive, emotional management, and social integration.
