INTRODUCTION

Population aging is a frequently mentioned aspect in Portugal. The average life expectancy in 1970 was 67.1 years and in 2019 it was 81.1 years old¹. Currently, human aging is seen as an increasingly long process accompanied by physiological and biological changes, often associated with degenerative processes that can compromise people's functional capacity². In this way, with the aging of the population come chronic pathologies which, in terms of hospital health care, modify the level and hours of care provided; the dynamics of Internal Medicine services are influenced and doors are opened that encourage a change in the hospitalization paradigm.

According to Temido et al (2018), the percentage of clients aged over 65 admitted to internal medicine services doubled, with the median age changing from 61 to 79 years old. There was also an increase in the number of secondary diagnoses (64.8% had 6 or more diagnoses), clearly illustrating the complexity of this population ³.

Analyzing the fact that 73.8% of the population aged over 65 has chronic illnesses and these alter their perception of health⁴, the work of RN in internal medicine services becomes essential.

The RN have as a fundamental objective in their professional action the maintenance and promotion of well-being, quality of life, promotion of self-care and recovery of functionality, prevention of complications and maximization of capacities ^5,6.

The RN are inserted in multidisciplinary teams and by having an intervention based on evidence, they lead to health gains, which are translated into years of life, reduction of episodes of illness or shortening of their duration, reduction of situations of disability, increase of functionality and reduction of avoidable suffering and improvement of quality of life⁷. Thus, the RN develop a set of activities that allow minimizing the effect of aging and recurrent hospitalization.

In 2017, the Directorate-General for Health highlighted the need to adapt health services to the elderly population, also highlighting the benefits of shorter hospital stays ⁸.

It is in this sense and with the aim of answering the following questions:

that this study appears, allowing to strengthen the evidence on rehabilitation nursing, a need identified by Fernandes, Gomes, Magalhães & Lima in 2019 ⁹.

In this way, it is intended to contribute to the dissemination of the care provided by the RN and its results in the health of citizens, allowing to generate knowledge, evaluate practices and provide evidence for teaching, thus contributing to the evolution of the profession¹⁰.

METHODOLOGY

A quantitative, cross-sectional and retrospective study was carried out in the context of a medical service at a hospital in the central-north region of Portugal.

The Medicine X service consists of (physically) 11 rooms with 36 beds. In the same physical space, the Neurology service operates, which consists of 4 beds. The rehabilitation nursing team provides specialized care to both services and, when requested, supports the inpatient Medicine Y and Stroke Unit. However, for this study, only beds referring to the Medicine X service were counted.

Through non-probabilistic sampling, all clients who had intervention from the RN and who were admitted to the service in the period between January 1, 2019, and December 31, 2020, were selected.

During the same period of time, that is, two years, data were collected. This period was selected since human resources in rehabilitation nursing doubled in 2020, a particularity that allowed for a more detailed analysis and comparison of the provision of RN care.

The data referring to the sample were collected through a grid previously created by the RN, which contained the client's file number, gender, age, the main pathology associated with the hospitalization, the start and end date of the intervention plan and the techniques used.

The interventions implemented in this period were grouped according to the information described in Diário da República n.º 132 (2017) ¹¹ and represented in table 1.

The remaining information, which allowed comparison with the selected sample, was requested from the SEPAG service at Hospital X. This was obtained through the records made in the computer systems by the institution's clinicians and technical assistants.

The data obtained were introduced and analyzed in the Excel® computer program, since it is a program that is easily accessible in Portuguese health institutions. Descriptive statistics were used using measures of central tendency and dispersion.

During the performance of this study, all the assumed ethical aspects were respected, so authorization was requested from the highest body for data collection and processing, these were treated ensuring the anonymity of the participants and the principles of academic integrity were complied with throughout the process.

RESULTS AND DISCUSSION

During the analyzed period, 1786 clients were admitted, of which 849 were male and 937 were female (table 2). The mean age was 77.5 years old. These results corroborate those of the Portuguese Society of Internal Medicine, which points out that the demography of clients hospitalized in internal medicine services has a clear prevalence of elderly age groups, with 76% of clients aged 70 or over ¹².

The average length of stay was 13.5 days with a median of 9.5 days (Table 2). The average length of hospital stay is higher than that presented in 2018 in the study carried out by Martins, Sanches and Carvalho, where they found an average delay of 9.5 days in an inpatient service with the same characteristics as a hospital in the interior of southern São Paulo. Portugal ¹³. This delay may be due to several factors, such as the aging of the population and diversification of the interior of the country, since it is a value that can be superimposed on data referring to previous years and other hospitals with a coverage area with similar characteristics. In the study carried out by Carvalho (2018), in 2015, the length of stay at the ARS Center varied between 8.65 days and 15.49 days ¹³.

During 2019, the rehabilitation nursing team of the Medicine X service consisted of one element with an individual work contract to work 35 hours a week, while in 2020, the same team consisted of two elements, totaling 70 hours weekly.

In this way, the team consisted of a rehabilitation nurse providing full-time specialized care for 1414 hours, approximately 176 days, calculated according to the formula presented in the standard for calculating safe allocations of nursing care ¹⁴, that is, 48.9% of the time, while in 2020 the team had a full-time rehabilitation nurse, every working day, for 83 days. In other words, 32.8% of working days had 2 rehabilitation nurses working simultaneously, although sometimes these elements were shared with two other inpatient services

Table 3 allows us to verify that, during the biennium, of a total of 882 clients who had intervention in rehabilitation nursing care, 440 were female and 452 were male with an average age of 80 years old (minimum of 23 years old and a maximum of 102 years old). The average duration of the rehabilitation program was 10 days, with a minimum of 1 day and a maximum of 60 days.

Of the total number of clients admitted in 2019 (906 clients), 323 had rehabilitation nursing interventions implemented, that is, 35.65% of clients were the target of this specialized practice. In 2020, 63.5% had implemented a rehabilitation plan, reflecting an increase of 27.9%.

In order to facilitate understanding, the most relevant interventions were selected (performed more often) presented in table 4. In total, in addition to these, 858 more specialized interventions were performed, making a total of 4130.

As can be seen in the same table, there was an increase in the number of interventions between 61.6% and 4.27%, with a negative value referring to aerosols since during the year 2020, due to contingencies related to the SARS-COVID19 pandemic it was not allowed to be carried out in the internment service.

The interventions that were most often carried out in the two-year period (respiratory kinesiotherapy, postural drainage, manual muscle strengthening) meet the assistance needs associated with the most frequent medical diagnoses in this service under study. These results corroborate the retrospective study by Martins, Sanches, & Carvalho (2018) where it was concluded that the main diagnoses referring to the admission of centenarian clients, in the Medicine service, during the period of 10 years, were related to: infectious pathology of the respiratory disease, dehydration, stroke and heart failure¹³, as well as the study by Mendes (2019) in which the main reasons for hospitalization in a medical service were: pneumonia, ischemic stroke and tracheobronchitis¹⁵.

Considering the year 2019 and observing Figure 1, we can see that there is an increase in hospitalized clients and rehabilitation nursing interventions in the winter period, with a slight decrease in the warmer months.

For this analysis, the year 2020 was not considered since it is an atypical year due to the SARS-COVID19 pandemic. There was a late access to health care by clients, which slightly modified their characteristics, so that the number of clients hospitalized per month or time of year cannot be compared with other years.

Source: own authorship

Figure 1: total interventions according to year and month 

CONCLUSION

In order to answer the questions posed in this study, and according to the results presented, it can be concluded that the clients of the medicine service X were characterized by having an average age of 77.5 years, with an average hospitalization of 13.5 days.

Comparing both years, in 2020 it was possible to include a full-time rehabilitation nurse, allowing the allocation of 2 rehabilitation nurses (although shared with other services), which provided the provision of rehabilitation nursing care to over 236 clients than in the previous year, that is, 27.9% more. There was also an increase in the number of interventions implemented, such as “muscle strengthening”, which was carried out 101 times more than in the previous year (61.6%). However, this number of rehabilitation nurses is insufficient, since they did not respond to all needs in specialized care, with only 63.5% of the clients of the Medicine X service being evaluated in the best year, which is clearly insufficient for the reality of an Internal Medicine service, whose target population is elderly clients, the vast majority with multimorbidity and with a high degree of dependence on self-care.

In this way, considering:

It recognizes the need to allocate more RN in Medicine services in order to prevent the consequences of immobility and promote the potential for rebuilding independence, given the specific characteristics of the older population, often hospitalized in this type of care.

Despite the contingencies, a high number of rehabilitation nursing interventions were carried out (4130 interventions to 882 clients). The areas that were most developed during this period were: respiratory kinesiotherapy (postural drainage and associated techniques), muscle strengthening/joint mobilization and balance and gait training. These interventions are associated with the most frequent pathologies in the service: diseases and disorders of the respiratory system, the circulatory system and the nervous system.

As a difficulty felt, it can be pointed out some complexity in accessing the data related to the Medicine X service and the reduced time available for recording and analyzing them.

The limitations of this study are essentially related to the short period analyzed and the impossibility of making some comparisons with the year 2020 due to the SARS-COV19 pandemic.

For future investigations, it is proposed to carry out randomized experimental studies that allow the concrete evaluation of the effectiveness of rehabilitation nursing intervention plans applied in Internal Medicine services and individualized programs should be created according to the most frequent nursing diagnoses in the field of rehabilitation.