INTRODUCTION

In the national and international context, the increase in the average life expectancy and the aging of the population, the therapeutic progress, and the improvement of the socioeconomic conditions have introduced significant change in the private life and in the public life of the current populations ¹.

Indeed, following aging and the higher prevalence of chronic diseases, the population's needs increasingly call for the intervention of specialist nurses in rehabilitation nursing ².

Rehabilitation nursing is an area of ​​specialized Nursing intervention that prevents, recovers and re-empowers people who are victims of sudden illness or decompensation of chronic pathological processes, which cause functional impairment at the cognitive, motor, sensory, cardiorespiratory level, of food, elimination and sexuality ³. In this sense, rehabilitation nursing care “focuses on maintaining and promoting well-being and quality of life, restoring functionality as much as possible, through promoting self-care, preventing complications and maximization of capacities”^{(3: 16656)}.

Aiming at the person, at all stages of the life cycle, the excellence of the professional exercise of rehabilitation nursing, in addition to bringing gains in health in all contexts of practice, has been positively influencing the quality of nursing care.

Over the past few decades, as result of the complexity of care and the increase in citizens' expectations, topics such as quality in health were considered as priorities, and the excellence of professional practice has been encouraged, which necessarily incorporates the provision of care services congruent with the quality standards defined for each of the domains, which characterize the social mandates of each of the professions ^4,5.

Once the challenge of quality and excellence in professional practice in the health field was launched in 2001, the Nursing Council of the Order of Nurses ⁶, having faced the challenge of defining the quality standards of nursing care, stated six categories of descriptive statements: customer satisfaction, health promotion, prevention of complications, well-being and self-care, functional readaptation and organization of nursing care.

Subsequently, in line with one of its statutory competencies, the College of Specialty in Rehabilitation Nursing defined the quality standards of specialized care in rehabilitation nursing ⁷, which after being approved, were published in Regulation 350/2015. The purpose of defining the quality standards of specialized rehabilitation nursing care was to make them “an essential tool for promoting the continuous improvement of this care and as a reference for reflection on the specialized practice of rehabilitation nursing” ^{(3: 16655)}. In this context, eight categories of descriptive statements were identified: customer satisfaction, health promotion, prevention of complications, well-being and self-care, functional readaptation, functional re-education, promotion of social inclusion and organization of nursing care.

Although the professional practice of rehabilitation nursing requires an action that is congruent with the specificity of the mentioned descriptive statements, in this study, we were interested in perceiving the contribution of specialist nurses in rehabilitation nursing to the quality of nursing care provided in hospital contexts. In fact, regardless of the area of ​​specialization, portuguese nurses must implement in their professional activity, interventions proposed by the quality standards developed by the Order of Nurses in 2001 ⁸. However, although efforts have been made over the past decade to implement the quality standards of nursing care ⁶ in hospital institutions, some weaknesses have been evident ⁵. In this sense, based on the research “Contexts of hospital practice and nursing conceptions: views on the real quality and the ideal of excellence in the professional practice of nurses”, this study aimed to understand the perception of nurses specialized in rehabilitation nursing, regarding the implementation of the quality standards of nursing care in a hospital context.

METHOD

In order to achieve the objective stated above, we opted for a quantitative approach. The study carried out was descriptive, exploratory in nature.

Although it was planned to carry out the study in all hospital institutions, within the management model of the Public Business Entity, which at the time of data collection were 38; due to the fact that two institutions did not accept to participate, the study was carried out in 36 hospital institutions EPE of mainland Portugal. Bearing in mind the ethical-legal principles, it should be noted that in order to obtain authorization for the study, a letter was sent to all hospital institutions, addressed to the Board of Directors, making the study known and requesting participation. Although the process inherent to authorizations varied from institution to institution, in the end, the study was approved by the ethics committees and respective boards of directors of the 36 institutions involved.

Due to the impossibility of studying the entire population, a sample was created. The sampling technique used was non-probabilistic for convenience ⁹. The inclusion criteria were defined as “be a specialist/specialized nurse in the field of rehabilitation nursing” and “exercise their professional activity in the hospital within a period of time equal to or greater than six months, in the departments of medicine and medical specialties, surgery and surgical specialties or intermediate and intensive care units ”. In this sense, all specialist nurses/specialists in rehabilitation nursing who performed functions in the services where the study was authorized and who agreed to participate, were included in the sample, which was made up of 306 specialist nurses in rehabilitation nursing. When clarifying the objectives, as well as the procedures inherent to the investigation, it was clear that their participation would be voluntary, being able to give up at any time, without being harmed. Nurses who agreed to participate in the study were asked to sign informed consent, with confidentiality and anonymity in the use and disclosure of the information obtained. For data collection, a self-administered questionnaire was used, consisting of two parts: Part I - Characterization of the Specialist/Specialized Nurse; Part II - Scale of perception of nursing activities that contribute to the quality of care. Based on the quality standards of nursing care ^6,10, this scale, built and validated in 2016 ⁴, presents a conceptual structure organized in 7 dimensions: customer satisfaction (3 items), health promotion (3 items), prevention of complications (3 items), well-being and self-care (4 items), functional readaptation (4 items), organization of nursing care (2 items) and responsibility and rigor (6 items). The scale of Likert-type responses varies between 1 and 4, with 1 corresponding to never, 2 to rarely, 3 to sometimes and 4 to always.

For the treatment of the data, the statistical program, Statistical Package for the Social Sciences (SPSS), version 22.0 was used.

RESULTS

Regarding the sociodemographic and professional profile of the participants, we found that of the 306 specialist/specialized nurses in rehabilitation nursing, most of them are female (71.2%). The average age is 38.4 years-old (with a standard deviation of 7.6) and the majority marital status is married (60.5%). With regard to the academic degree, the majority is a bachelor degree (74.84%), followed by a master's degree (24.84%) and a doctorate degree (0.32%).

Regarding the distribution of specialist/specialized nurses according to the regions of the regional health administration to which the hospital institutions belong, 49.3% are from the North, 21.6% from Lisboa e Vale do Tejo, 20.6% from the Centre, 5.2% from Algarve and 3.3% from Alentejo.

With regard to the context in which they exercise functions, the services of medicine and medical specialties predominated (47.1%), followed by surgery and surgical specialties (38.2%) and intermediate and intensive care units (14.7%).

As for professional practice in the specialty area, the average time was 3.7 years (with a standard deviation of 4.7), with a minimum of 0 years and a maximum of 23 years. The minimum value of 0 years is explained by the fact that 132 nurses (43.1%) with specialization courses in rehabilitation nursing, who participated in the study, do not exercise their professional activity in the specialty area. The average time of professional practice in the current service was 8.8 years (with a standard deviation of 7.0), with a maximum of 32 years and a minimum of 1 year.

Regarding training in the quality standards of nursing care, 159 specialist/specialized nurses (52.0%) reported that they performed it.

Following the application of the scale of perception of nursing activities that contribute to the quality of care⁴, built on the basis of quality standards issued by the Order of Nurses⁶, within the dimension of customer satisfaction (Table 1) , it was possible to verify that the activity respects the capacities, beliefs, values ​​and desires of individual nature of the clients in the care they provide, “Always” was the majority answer (73.86%), followed by “Sometimes” (25, 16%) and “Rarely” (0.98%), with no answers for “Never”.

Regarding the activity, it constantly seeks empathy in interactions with customers (patient/family), “Always” was the majority answer (79.74%), followed by “Sometimes” (19.93%) and “Rarely”(0.33%), with no “Never ”responses.

Regarding the activity, which involves the significant companions of the individual client in the care process, “Sometimes” was the majority answer (52.29%), followed by “Always” (42.16%) and “Rarely” (5 , 55%), with no “Never” answers.

Considering the health promotion dimension (Table 2), it was found that in the activity, it identifies the health situations and resources of the client/family and community, “Sometimes” was the majority answer (60.46%), followed by “Always” (33.66%), “Rarely” (5.55%) and “Never” (0.33%).

Regarding the activity that uses hospitalization to promote healthy lifestyles, “Sometimes” was the majority answer (54.58%), followed by “Always” (35.29%), “Rarely” (9.48% ) and “Never” (0.65%).

Regarding the activity, it provides information that generates cognitive learning and new skills by the client, “Sometimes” was the majority answer (54.57%), followed by “Always” (37.58%), “Rarely” (7.52%) and “Never” (0.33%).

Within the scope of the prevention of complications dimension (Table 3), it was found that in the activity, it identifies the potential problems of the client, “Always” was the majority response (63.1%), followed by “Sometimes” (36.6% ) and “Rarely” (0.3%), with no “Never” answers.

With regard to the activity, prescribes and implements interventions aimed at preventing complications, “Always” was the majority answer (65.7%), followed by “Sometimes” (34.0%) and “Rarely” ( 0.3%), with no “Never” answers.

Regarding the activity, it evaluates interventions that contribute to avoiding problems or minimizing undesirable effects, “Always” was the majority answer (60.1%), followed by “Sometimes” (38.6%) and “Rarely” (1.3%), with no “Never” answers.

With regard to the well-being and self-care dimension (Table 4), it was found that the activity, identifies the client's problems that contribute to the well-being and performance of life activities, "Always" was the majority answer (62, 74%), followed by “Sometimes” (35.62%), “Rarely” (1.31%) and “Never” (0.33%).

Regarding the activity that prescribes and implements interventions that contribute to increasing the clients' well-being and performance of life activities, “Always” was the majority answer (59.5%), followed by “Sometimes” (37.9 %), “Rarely” (2.3%) and “Never” (0.3%).

With regard to the activity, it evaluates interventions that contribute to increasing the well-being and performance of the clients' life activities, “Always” was the most frequent answer (55.88%), followed by “Sometimes” (39.54%), “Rarely” (4.25%) and “Never” (0.33%).

Regarding the activity referring to identified problematic situations that contribute to the well-being and performance of the clients' life activities, “Always” was the majority answer (50.3%), followed by “Sometimes” (45.4% ), “Rarely” (3.6%) and “Never” (0.7%).

Given the functional readaptation dimension (Table 5), it was observed that in the activity, the process of providing nursing care continues, “Always” was the majority answer (73.2%), followed by “Sometimes” (25 .5%), “Rarely” (1.0%) and “Never” (0.3%).

Regarding the activity, it plans the discharge of clients admitted to the health institution, according to the clients' needs and community resources, “Always” was the most frequent answer (51.0%), followed by “Sometimes” (41.8%), “Rarely” (5.9%) and “Never” (1.3%).

Regarding the activity that optimizes the capabilities of the client and significant partners to manage the prescribed therapeutic regimen, “Always” was the most frequent answer (51.3%), followed by “Sometimes” (40.2%), “Rarely” (8.2%) and “Never” (0.3%).

Regarding the activity teaches, it instructs and trains the client on the individual adaptation required in the face of functional readaptation, "Always" was the most frequent answer (54.9%), followed by "Sometimes" (37.3%), “Rarely” (7.5%) and “Never” (0.3%).

Regarding the dimension of organization of nursing care (Table 6), it was found that in the activity the nursing records system dominates, “Always” was the majority answer (53.6%), followed by “Sometimes” (41.5%), “Rarely” (4.9%), with no answers to “Never”.

Regarding the activity, knows the hospital policies, “Sometimes” was the majority answer (53.3%), followed by “Always” (36.9%) and “Rarely” (9.8%), with no any “Never” responses.

When analyzing the dimension of responsibility and rigor (Table 7), it was possible to realize that the activity, demonstrates responsibility for the decisions it takes, for the acts it practices and delegates, with a view to preventing complications, “Always” was the majority answer (91 .2%), followed by “Sometimes” (8.8%), with no answers to “Rarely” and “Never”.

With regard to the activity, it demonstrates responsibility for the decisions it takes, for the acts it practices and delegates, in view of the clients' well-being and self-care, "Always" was the majority answer (86.9%), followed by “Sometimes” (12.4%) and “Rarely” (0.7%), with no answers to “Never”.

Regarding the activity, it demonstrates technical/scientific rigor in the implementation of nursing interventions, with a view to preventing complications, “Always” was the majority answer (82.4%), followed by “Sometimes” (17.6%), there are no answers to “Rarely” and “Never”.

Regarding the activity demonstrates technical/scientific rigor in the implementation of nursing interventions that contribute to increasing the well-being and performance of the clients' life activities, "Always" was the majority answer (77.5%), followed by “Sometimes” (22.2%) and “Rarely” (0.3%), there are no answers to “Never”.

Regarding the activity, it refers to problematic situations identified for other professionals, according to the social mandates, “Always” was the majority answer (57.8%), followed by “Sometimes” (40.2%) and “Rarely” (2.0%), with no answers to “Never”.

In the activity, he/she supervises the activities that implement the nursing interventions and the activities he/she delegates, "Always" was the majority answer (59.2%), followed by "Sometimes" (36.6%) and "Rarely" ( 4.2%), with no answers to “Never”.

DISCUSSION

Following the analysis of sociodemographic variables, we found that most nurses who participated in the study were female (71.2%) and had a mean age of 38.4 years-old. As for the academic degree, the degree was the majority (74.84%). These results, in addition to reflecting the sociodemographic reality of nursing professionals, corroborate the data updated by the Ordem dos Enfermeiros ¹¹ regarding the area of ​​specialization in rehabilitation nursing. With regard to the length of professional practice in the specialty area, although it ranged between 0 and 23 years, the average time was 3.7 years. It should be noted that 43.1% of the nurses who participated in this study do not exercise their professional activity in the specialty area, which, once again, reveals the lack of use of the nurses' qualifications ⁵. According to data from the Ordem dos Enfermeiros, in December 2016, 46.8% of portuguese nurses with a specialization in rehabilitation nursing exercised their professional activity within the scope of provision of general care ¹¹, which is in line with the results obtained in this study.

Although the quality standards of specialized care in rehabilitation nursing have been defined since 2011, given the weaknesses identified in hospital contexts within the scope of a congruent performance with the quality standards of nursing care ¹², this study allowed us to clarify the contribution of specialist/specialized nurses in rehabilitation nursing to the quality of nursing care. Established in 2001 by the Ordem dos Enfermeiros, the quality standards of nursing care aim to improve the quality of the service provided⁸, thus requiring practices that are congruent with them, regardless of the condition in which nurses exercise the profession.

Thus, in order to identify how specialist/specialized nurses in rehabilitation nursing operationalize the quality standards of nursing care, it makes perfect sense to address the practices of these professionals in relation to all descriptive statements.

In this context, with regard to customer satisfaction, although the answers sometimes and always were the majority in the three activities of this dimension, when we compare the results with the study published in 2017⁵, we found that a higher percentage of specialists nurses in rehabilitation nursing evidence “involving the individual client's significant menbers in the care process”.

Although specialist nurses apparently show greater concern with the health promotion dimension, similarly to other studies carried out ^5,8, the majority response in the three activities that materialize this dimension was sometimes. Currently, and as it has been advocated by several authors⁸, although the client needs to develop skills and competences that facilitate their adaptation to the various stages of their life cycle and to their health and disease processes, the professional help of nurses will be a facilitating factor. For this, regardless of the context of professional practice, it is necessary to implement interventions in the field of health promotion, aim at empowerment and the development of strategies that help the client to manage the weaknesses caused by the different transitions he experiences. The problem is that in the hospital context, contrary to what has been evident in primary health care and continuing care, health promotion practices have not been properly incorporated by nurses yet ^5,8,12-13.

With regard to the prevention of complications dimension, the answer always has been the majority in all activities. In addition to corroborating the results obtained in another study ⁵, it proves, once again, the relevance of professional practice focused on the prevention of complications, that is, the potential problems of clients and intrinsic and extrinsic risk factors, whose control requires the intervention of nurses⁸.

In the context of well-being and self-care, while general care nurses always identify clients' problems, but only sometimes prescribe, implement and evaluate interventions that contribute to increasing well-being and self-care⁵, the results obtained in this study, demonstrate that specialist/specialized nurses in rehabilitation nursing mostly always perform all activities. In this sense, in addition to always identifying clients' problems, prescribing, implementing and evaluating interventions, in the activity "refers to identified problematic situations that contribute to the clients' well-being and performance of life activities", the participants also responded mostly ever. Since the activities inherent in this descriptive statement incorporate the phases of the nursing process⁸, the concern of specialist/specialized nurses with its operationalization is implicit. In fact, as stated within the scope of their specific competences, specialist nurses in rehabilitation nursing, design, implement and monitor differentiated care plans, based on people's real and potential problems, in order to maximize their potential, avoiding incapacities or minimizing their repercussion².

With regard to functional readaptation, in all activities that make this dimension a reality, the answer always has been the majority. By analyzing all the results obtained in this study and comparing them with those of another investigation already carried out⁵, it is in this descriptive statement that the differences are most notorious. In fact, specialist/specialized nurses in rehabilitation nursing, in the search for excellence in their professional practice, place a special focus on developing effective adaptation processes with clients. In this sense, in addition to continuing the process of providing nursing care, they plan the discharge of clients according to their needs and the resources of the community, optimize the client's capacities and significant cohabitants to manage the therapeutic regimen, they teach, instruct and train the client on the individual adaptation required in view of functional readaptation.

Within the scope of the organization of nursing care, the responses of general care nurses⁵ and specialist/specialized nurses in rehabilitation nursing are overlapping. Both responded mostly in the activity “dominate the nursing records system”, and sometimes in the activity “know the hospital policies”.

Regarding the responsibility and rigor dimension, in line with the results obtained in another study ⁵, in all activities the majority response was always. However, it is important to highlight that the percentage values ​​associated with the response always are higher among specialist/specialized nurses in rehabilitation nursing, which reveals the increased responsibility to promote the quality of nursing care provided in different contexts¹⁴.

Similar to other investigations in which general care nurses and nurses from other areas of specialty participated, the responses of specialist/specialized nurses in rehabilitation nursing, globally, showed a practice that was congruent with the quality standards of nursing care.

As a result of the analysis carried out, it was clear that the contribution of these specialist nurses to the quality of nursing care provided in hospital contexts is specifically centered on the descriptive statements of well-being and self-care and functional readaptation, which effectively translate the core of the specialty area of rehabilitation nursing, as well as its social mandate. On the other hand, and although health promotion is currently considered a priority area, it is one that, in the context of general care and specialized care, has been neglected, particularly in the hospital context. Rehabilitation nursing specialist are required to rethink their practices in order to help clients reach their maximum health potential. Furthermore, hospital admission must be seen as an opportunity to promote health, and not just as time dedicated to treat and cure the disease.

Despite the contributions of this study, we assume as a limitation the fact that the sampling technique used was non-probabilistic, which determines the possibility that the profile of specialist/specialized nurses who participated in the study influenced the results.