INTRODUCTION

Every human being carries with him an individual representation of death. This is created by the influence of social life, the media and the particularities of each individual. "It is in this scenario of diversity regarding death that nursing professionals find themselves, living in constant challenge, as they remain in conflict on a daily basis, fighting for life and against death, taking upon themselves the responsibility to save, cure or alleviate, always seeking to preserve life, since death, in most cases, is seen by these professionals as a failure, being, in this way, harshly fought”^(1:42).

We are creating more and more subspecialties that try to more or less artificially prolong the beauty and the vital functions and postpone this moment which, despite all our commitment and efforts, remains unsurpassed. "Consequently, this extension implies the need for differentiated care, based on valuing the quality of life and the biopsychosocial and spiritual well-being of the patient, aiming to direct health care and, in particular, nursing, through an holistic and integral vision, revealing a “humanized care” ^(2:318).

Health professionals in general and nurses in particular, are empowered to help others to solve their problems, to promote health and to encourage healthy lifestyle habits. In fact, they are not prepared to accept that there are limits that they will not always be able to treat and restore health to the sick person, so they have to invest in their well-being. And if the aforementioned is notorious in general care nurses, we wonder if it will also be the case for specialist nurses.

According to the Regulation of Common Skills of Specialist Nurses³, there are four areas of competence: professional, ethical and legal responsibility; continuous quality improvement; management of care and development of professional learning.

Within the scope of the problem under study, in the field of professional, ethical and legal responsibility, we emphasize that specialist nurses should promote care practices that respect human rights and professional responsibilities, namely in situations that are potentially compromising for clients. As an evaluation criteria, we highlight respect for values, customs, spiritual beliefs, as well as for the specific practices of individuals and groups in all phases of the life cycle³.

According to the same regulation, the nurse acts proactively promoting the appropriate involvement for well-being and managing the risk, for quality improvement by considering the management of the person-centered environment as an essential condition for therapeutic effectiveness and for the prevention of incidents. Regarding the evaluation criteria, we highlight sensitivity, awareness and respect for the spiritual needs of the individual/group and the involvement of the family and others in order to ensure that cultural and spiritual needs are met³.

Within the scope of the specific competences of the Specialist Nurse in Rehabilitation Nursing⁴, we emphasize the fact that specialist nurses take care of people with Specific needs, throughout their entire life cycle, in all contexts of care practice.

Thus, assuming that the professional practice of nurses specializing in rehabilitation nursing must be supported by instruments that regulate professional practice, as well as by theoretical nursing frameworks⁵, we question the visibility of this area of ​​specialty within the scope of of the records made in the information systems, namely the assistance to people in the process of dying.

It should be noted that prior to the emergence of computerized information systems, nursing records, as they are traditionally named by nurses, were characterized by the use of free text in order to produce narratives of the care provided, whose interest was limited to the production of documents with legal value⁶. Nowadays, as a result of the observed evolution, despite the notorious quality of the records, do they reflect in all situations the care provided within the scope of specialization in rehabilitation nursing?

Based on this concern, integrated in the broader research project "Living Death: a challenge for the nursing profession", we pose the following question: Does the documentation carried out by specialist nurses in rehabilitation nursing express their practice during death and the process of dying?

In line with the above, the objective of this study was to analyze the nursing focuses/diagnoses documented by specialist nurses in rehabilitation nursing, in caring for people in the face of death and the processes of dying.

METHOD

Descriptive, retrospective and quantitative study, carried out in the departments of Medicine, Surgery and Intensive care medicine, of a university hospital in northern Portugal.

The data on the documentation of nursing focuses/diagnoses identified in clients who died in 2016 were collected in February 2017 through two information systems: SCclinical and BICUcare structured based on the International Classification for Nursing Practice (CIPE®) version (2. 36,281 records were analyzed from 1270 nurses. Subsequently, following a non-probabilistic and intentional sampling, 9202 records were analyzed from 320 specialist nurses, of which 4,115 were carried out by 148 specialist nurses in rehabilitation nursing. Exclusion criteria were defined as: records of clients under the age of 18, records without clear identification of the nurse's authorship and records made outside the areas of medicine, surgery and intensive care.

For data treatment, we used the Statistical Package for Social Sciences (SPSS), version 22.0, and according to the nature of the variables and the objectives of the study, we used descriptive statistics.

RESULT

Out of the 320 nurses who have a specialization in nursing and who registered the patients who died, in addition to the predominance of the female gender (65.5%), the specialization in rehabilitation nursing was the one that appeared most frequently: 148 nurses (46 .3%).

The age of nurses with a specialization in rehabilitation nursing varies between 25 and 55 years-old, with an average of 36.8 years-old.

Regarding the services where specialist nurses in rehabilitation nursing work, services from the departments of surgery and medicine were predominant (Table 1). Specialization in medical-surgical nursing was more frequent among nurses who exercised their professional activity in the intensive care medicine department.

The distribution of records relating to the Individual focuses made by nurses with specialization in rehabilitation nursing (RN) is explained in Table 2.

Regarding the Function focus, 2408 (43.0%) records were made by nurses with specialization in rehabilitation nursing, distributed by the three areas, as shown in Table 3.

The distribution of records relating to the areas of attention assigned to the Function focus can be analyzed in Chart 1. We emphasize that there are four focuses (Physical Development, Metabolism, Nutrition and Repair) without any record.

The reduced number of records of nurses with different specializations, in the services of the departments of medicine and surgery, prevents the carrying out of any statistical test, as in fact, in these two areas there are almost only records of nurses specializing in rehabilitation nursing. It is only possible to observe the distribution of electronic records of nurses holding different specializations in the departments of medicine and surgery is very similar, clearly distinguishing it from the distribution of the intensive care medicine department. In fact, in this last department, the specialization in Medical-Surgical Nursing has greater representation, with the opposite happening with Rehabilitation Nursing. It should be noted that in this study the remaining specializations are almost meaningless.

The records relating to the Integument focus made by specialist nurses in rehabilitation nursing are the most frequent in the services of the departments of medicine (488 records - 44.4%), intensive care (446 records - 30.7%) and surgery (111 records - 40.8%).

The registers in relation to the Motor Activity focus, carried out by specialist nurses in rehabilitation nursing are also one of the majorities, noting the existence of 488 registers (71.9%). The largest number of these records is in the services of the department of medicine (276 records - 95.8%).

The records made by specialist nurses in rehabilitation nursing are still high in the case of the Breathing (468 records - 57.4%), Sensation (110 records - 57.4%), Elimination (103 records - 30.9) outbreaks %) and Digestion (75 records - 51.4%). With regard to the Breathing focus, nurses with specialization in rehabilitation nursing and who work in services in the department of medicine are the ones who register most in this area of ​​care (259 records - 77.3%).

In the Circulation focus, the records made by specialist nurses in rehabilitation nursing were 68 (30.8%). Of these 68 records, 49 were made in the intensive care department.

The distribution of records related to the focus Volume of fluids performed by specialist nurses in rehabilitation nursing corresponds to only 31 records (27.0%). Regarding the focus Body temperature, specialist nurses in rehabilitation nursing made 18 records (34.0%). Regarding the distribution of records made by specialist nurses in rehabilitation nursing in relation to the Immune System focus, we found there is only one record in the Surgical area and another in the Medical area.

As for the records related to the Person (Table 4), according to the areas of specialization, specialist nurses in rehabilitation nursing are the ones with the highest number of records (1707 records - 47.4%), namely in the services of the department of medicine.

The records related to the Focus Action (Table 5) made by specialist nurses in rehabilitation nursing were 1618 (46.7%).

In the distribution of records related to the Interdependent Action focus, the records of specialist nurses in rehabilitation nursing (Table 6) are the majority (48 records - 75.0%)

The records of the different focuses corresponding to the Interdependent Action area can be analyzed in Chart 2.

It should be noted that the records relating to the Communication focus (8 records - 72.7%), Role Interaction (9 records - 52.9%) and Social Interaction (31 records - 86.1%) are mostly made by specialist nurses in rehabilitation nursing. No records were identified regarding the Sexual Interaction focus, nor the Care Provider focus.

Regarding the records made by nurses regarding the focus Action Performed by the Self, according to the areas of specialization, specialist nurses in rehabilitation nursing are the ones with the highest number of records (1570 records - 46.2%). Chart 3 shows the areas of attention in relation to the focus Action Performed by the Self.

With regard to records made in the context of Self-care, according to the areas of specialization, specialist nurses in rehabilitation nursing are the ones with the highest number of records (1570 records - 46.2%).

Regarding the Lifestyles focus, none of the nurses with specialization in nursing made records, with only 6 records made by general care nurses.

Regarding the area of self-care attention (Chart 4), the records of specialist nurses in rehabilitation nursing are essentially directed to the focuses of Physical Activity (533 records - 55.5%), Self-care (271 records - 17.3%), Use of toilets (225 records - 43.1%), Hygiene (218 records - 40.7%), Clothing (188 records - 39.5%) and Personal Care (130 records - 38.1%). Regarding the Health Seeking Behavior focus, there were 4 records and 1 record in the Sleep-Rest Behavior focus.

Within the scope of the documentation carried out in relation to the Reason for Action focus, according to the areas of specialization, specialist nurses in rehabilitation nursing are the ones with the highest number of records (89 records - 65.9%), namely in the domain of Self- knowledge. The only record related to Self-concept, made by a specialist nurse in rehabilitation nursing, refers to Self-esteem.

Regarding Self-knowledge (Chart 5), according to the areas of specialization, specialist nurses in rehabilitation nursing are the ones with the highest number of records (88 records or 65.7%). Regarding the distribution of records made, according to specialization areas, for specialist nurses in rehabilitation nursing, the main focus was Memory (26 records - 57.8%), Adaptation (23 records - 71.9%), Energy (22 records - 64.7%) and Cognition (15 records - 88.5%).

Regarding the distribution of records made regarding the Emotion focus, according to the areas of specialization, Mental Health and Psychiatric Nursing is the most frequent (3 records - 50.0%), followed by Rehabilitation Nursing, with 2 records ( 33.3%) performed in the Medical area.

Regarding the distribution of records related to Willpower, nurses with specialization made only 1 record, which was carried out by a nurse with specialization in Mental Health and Psychiatric Nursing.

Regarding the Learning, Well-being, Belief and Decision Making focuses, there were no records of any of the areas of specialization

DISCUSSION

The use of electronically supported information systems has increased significantly, a reality to which nursing has not been left out. In the investigations carried out by several authors^6-8, it was possible to verify that the information system favors the guarantee of the continuity of nursing care, as well as its visibility. In an investigation carried out in the hospital context⁹, it was found that nurses are aware of the importance of the electronic information system, seeing in its implementation the possibility of giving visibility to the care provided. In this context, it is important to remember that nursing documentation is an essential component, with clinical and legal significance, and a poor documentation standard contributes to a worse quality of care¹⁰.

Despite the advantages of an electronic information system, in order to facilitate communication between institutions and ensure the possibility of comparing nursing data, in 2007, the Nursing Order, considered that one of the basic principles for the development of the nursing system information was the use of the International Classification for Nursing Practice (ICNP®) as a language reference¹¹.

Information systems have been seen as an instrument to facilitate research in nursing. In relation to the above, it has been considered that, in addition to constituting a strategic resource for management, the possibility of reusing the data documented in the information systems, in the form of sensitive indicators for nursing care, paves the way for the consolidation of the role and the importance of nurses¹² and, particularly, specialist nurses in rehabilitation nursing. For this, it will be necessary, first of all, to solve the problem of under-documentation of nursing care¹², and in this particular case, of rehabilitation nursing. The identification of some factors that may justify this under-documentation can contribute to the adoption of strategies that culminate in the optimization of the information system in use.

In this sense and in the context of a study carried out in the national context¹³, five factors emerged that condition the valuation of electronic information systems: inequalities between institutions regarding the updating of the computerized information system; the complexity of the computerized information system; the inadequacy of the computerized information system in some contexts; knowledge of the computerized information system, as well as the time for electronic records.

The idea that there is too much time devoted to documentation continues to prevail among nurses. In an investigation carried out in 2006, it was found that the difficulties inherent in handling computers could increase the time spent, however, with the training of these skills, better time management would be possible⁶. Furthermore, given the current levels of technological literacy, it was thought that the difficulties inherent in handling computers would have little influence¹⁴, which effectively does not always happen.

The problem is that from the perspective of some nurses, regardless of computer technology skills, it is necessary to spend a lot of time on the computer, in order to meet all the requirements inherent in the documentation of planned and provided care. As already mentioned in 2006, “the time nurses spend to document competes with the time available for direct care to clients”^(6:18), which often culminates in an under-documentation of care, in this case, rehabilitation nursing.

In this subject, the unavailability of time is also reflected in the lack of updating of the care processes in the computerized system, with changes in status frequently occurring without updating of the other aspects included in the care plan. It is, therefore, notorious that the time spent to carry out nursing records can interfere with their quality¹⁵.

Within the scope of the factors that condition the documentation of nursing care, the appreciation of the documentation of nursing care stands out, as well as the knowledge about the importance of documentation of nursing care¹³.

As it was already pointed out in the literature, the challenge is to recognize the importance of the records, as they reflect what was actually performed, with the risk of incurring in the question, "if it is not registered, then it was not performed"^(15:34). Since the information documented by nurses was used in the study presented here, the question stands out: do specialist nurses in rehabilitation nursing not register the problems and needs of people in the context of death and dying processes, or will it be a less valued area in the scope of your performance?

From the above, the need to clarify the aspects inherent to the informative quality of the documentation emerges in the contexts, since incomplete data mischaracterize the reality, the intervention of health professionals and compromise the adoption of evidence-based strategies^16,17.

As a result of the institutionalization of death, nurses who exercise their professional activity in hospital institutions, such as the nurses who participated in this study, are often faced with the need to care for people in the process of dying and the studies that have been carried out in these contexts show that they do not always feel prepared, since the academy trains professionals with theoretical and practical support to preserve life, and the issues of death and dying are hardly addressed^18-22. The problem is that the superficiality and trivialization of the few discussions about death and the process of dying have not allowed the expansion of the understanding of this phenomenon as an integral event of the life cycle¹⁹.

Following the above and given the results obtained in this study, it is emerging that nurses defocus from a practice predominantly dedicated on meeting basic human needs, in favor of a care centered on the experiences lived by people in the face of the imminence and inevitability finitude of life, with the potential to culminate in a dignified and peaceful death²³.

When analyzing the records, according to the areas of specialization, specialist nurses in rehabilitation nursing are the ones with the highest number of records in the scope of the "Person" and the "Action performed by the Self", which shows, once again, the value attributed by these specialist nurses to each person's individual project.

The documentation carried out in the scope of the function shows that despite the value attributed to the person's domain, specialist nurses in rehabilitation nursing give special focus to three areas of care: integument, motor activity and breathing.

Given the characteristics of the professional practice of specialist nurses in rehabilitation nursing, the focus on the integument is perfectly integrated in the prevention of complications. On the other hand, the performance centered on motor activity and breathing, show the contribution of the specialist nurse in rehabilitation nursing in maximizing the person's potential, and for this purpose, they conceive, implement and monitor differentiated rehabilitation nursing plans, based on the real and potential problems of people in three essential components: motor, neurological and cardiorespiratory.

Since the care provided in the context of death and dying processes needs to be anchored in theoretical nursing frameworks²³, from the results related to the focus “Reason for action” emerges the need to rethink practices. In fact, the absence of records in the scope of learning, well-being, belief and willpower, crucial in the scope of some of the theoretical nursing frameworks, highlights the need for the design and respective documentation of care to contemplate these areas, which are essential during the experience of transitions. In addition, the inclusion of these areas of care will ensure that nurses are able to recognize not only the biological aspects, which are highly focused on the function, but also the psychosocial and spiritual implications of the experience of death and the processes of dying in patients, families and in family caregivers²³.

CONCLUSION

Hospital institutions have undergone significant changes, aiming either at satisfy customer needs or at the quality of the service provided. Due to these requirements, the correct documentation of customer problems and needs is essential to the success of any organization.

However, despite the relevance currently attributed to the documentation of rehabilitation nursing care, there are some weaknesses, especially relating to the updating of the care process. In fact, despite identifying the problems and needs of clients in the context of death and dying processes, they are not always registered, which raises doubts as to their implementation.

Although it is known that the performance of nurses is not always congruent with the theoretical frameworks of the discipline and with the instruments that regulate professional practice, several studies have shown that what is performed is significantly higher than what is recorded. In view of the above, in addition to the documentation carried out by nurses being crucial, it would be interesting to carry out qualitative studies in order to identify the factors that facilitate or compromise a congruent performance with the regulatory instruments of the profession and with the theoretical frameworks of the discipline and/or on the other hand, compromise the documentation of what was planned and executed. It would be equally interesting, although not within the scope of the project “Living death: a challenge for the nursing profession”, to compare these results with the records made by specialist nurses in rehabilitation nursing on other clients.