INTRODUCTION

Modern nursing dates from less than 3 centuries, originating in the Nightingalean period, in the middle of the Crimean war, which resulted in thousands of soldiers wounded and with the consequences of these injuries. The wars of yesteryear, like the present ones, result in deaths and injuries that often become people with disabilities. We must register two issues of this origin: it is recent (we do not have 300 years of modern profession), and its beginning was predominantly in the care of injured people and the consequences of these injuries.

If modern nursing is recent, it is unnecessary to mention rehabilitation nursing, aimed at people with sequelae of wounds/injuries or chronic-degenerative diseases who, due to this, have difficulties in performing tasks considered common in everyday life, needing to relearn how to do them. Authors ¹ attest that rehabilitation nursing has its historical origin in the two great world wars, due to the need to put wounded and disabled soldiers back into battle or back to their homes having as a central focus the physical disability and functional losses.

Rehabilitation nursing means

“A philosophy of nursing care based on rehabilitative and restorative principles. The goals of rehabilitation nursing are to maximize functional skills, optimum health and adapt to changes in lifestyle. Rehabilitation nursing is the provision of nursing care to individuals and their families, who are going through temporary, progressive or permanent health situations, which change their lives, such as chronic illness, disability, frailty and aging ^{(2; 1)}.”

It can also be understood as

“A body of knowledge and specific procedures that focus on maintaining and promoting well-being and quality of life, restoring functionality when possible, promoting self-care, preventing complications and maximizing capabilities. (…) Rehabilitation care address the Person at all stages of the life cycle (…)”^{(3; 6)}.

These two views show that rehabilitation nursing is not located in a single area of ​​health care, being a specialty that operates in all vital cycles (from birth to old age) and health-disease processes (from healthy to death). It is aimed at the person, his family, environment and communities, with the objective of promoting changes in lifestyle, in order to make people with functional deficits and their families, citizens with the ability to socially contribute, interact and live well.

This essay aims to outline a brief current overview of rehabilitation nursing, focusing on: which countries have this specialty, the relevant organizations and legislation, as well as the similarities and differences between the different locations. Hopefully, with this, to contribute to the reflection on this area of ​​assistance, research and knowledge, and to give it a greater visibility.

METHODOLOGY

It is a descriptive and retrospective study, with research in databases of official websites, carried out from the eduroam network, as it allows to access to several recognized databases. The wealth of information available is unquestionable, which makes it necessary to use new methodologies in order to investigate the advancement of knowledge in the various areas. The bibliographic review, provided it is based on scientific criteria of reproducibility, is a recent tool that helps researchers to know and to analyze trends in knowledge ⁴.

The data were collected from February 2 to March 31, 2018. The entities associated with the International Council of Nursing - ICN were researched. The ICN dates from 1899, is based in Geneva, Switzerland, and is considered to be the world nursing representation body. Its objectives are to defend nurses, to advance the profession and to influence health and training policies ⁵.

From this website, all countries (134) associated with the International Council were investigated on their websites of the Ministry of Health, Ministry of Education, Nursing legislation, Universities with postgraduation degrees in nursing, associations and professional organizations (Councils or Orders) , in addition to the website indicated in the ICN.

This presents 134 countries whose representative nursing entities are linked to it. From this, the following words related to each country were searched: "nursing", "nursing legislation", "rehabilitation nursing", in Portuguese, English and Spanish. Countries that did not contain information in these languages ​​were excluded. The data were organized by folders with the name of each country and all material (legislation, public policies focused on the area, associative entities and competences and supervision of the area) were classified. The flowchart below shows the data search:

Source: The authors

* Countries with legislation recognizing the specialty were considered, regardless of whether or not they work in rehabilitation or postgraduate training centers.

** Respectively: France, Holland, Russia, Seychelles and Switzerland. France presented some documents in Spanish and/or English, which made it possible to analyze them.

Figure 1 Flowchart of the data collection strategy on countries with Rehabilitation nursing. 

Then, in each country, professional orders, rehabilitation nursing associations, congresses and meetings in the area and policies aimed at training nurses and people with disabilities were investigated.

RESULTS

124 countries were surveyed in the places previously described, and, out of these, 111 countries do not

have rehabilitation nursing as a legally recognized profession, as shown in the map below.

Source: the authors

* Only countries with proven legislation in the mentioned languages were assessed. The authors consider the possibility of other countries whose legislation is not available.

Figure 2 World map showing which countries * have rehabilitation nursing as a specialty. 

The countries with rehabilitation nursing found were: Australia, Canada, The United States of America, France, Guatemala, England, Mexico, Holland, New Zealand, Portugal, Russia, Seychelles and Switzerland. Russia and Seychelles were subsequently withdrawn for failing to meet the language criteria in official documents. France presented abundant material related to the meetings of the specialty, which is why it was mentioned later.

The data were read exhaustively, at first from each country individually, and at a second moment, resulting from this first, divided into the following themes in rehabilitation nursing: legislation and government policies, associative entities, professional skills.

Out of the 13 countries found, 5 were excluded for not meeting the language criteria. Even so, the HDI and Life Expectancy data were considered for further analysis.

The investigated countries have entities representing the specialty and hold meetings with specific themes, as shown in Table 2.

No specific events were found in Mexico, Guatemala, Holland, the United Kingdom, Seychelles and Switzerland. There are countless meetings, worldwide, aimed at rehabilitation - with the title of "physical medicine and rehabilitation" or physiotherapy. However, the table above shows which ones were specific to the rehabilitation nursing specialty. In those countries with the specialty and without representative entities of rehabilitation nursing, no specific events were found.

The United Kingdom has a Rehabilitation Council, formed by those interested in the field (from professional associations to users) created in 2008 and with the financial support of the Department of Labor and Pensions and the Scottish Center for Healthy Working Lives. Its purpose is to guarantee access to quality rehabilitation. Nursing entities in the United Kingdom are an integral part of this Council ⁷.

There is also an international entity of spinal cord injury nurses, called the International Spinal Cord Society (ISCoS), a spinal cord injury nursing network, whose aim is to "link nurses globally, working in the spinal cord injury specialty, [through ] improvement of holistic care provided to men, women, boys and girls, their caregivers and families, with spinal cord injury ⁸". On the four international meetings mentioned, specific topics on spinal cord injury were discussed, including neurogenic bladder and intestine, skin care and sexuality. ISCoS does not aim at rehabilitation, only specific care.

DISCUSSION

Most countries establish that professional nursing practice aims to “promote health, to prevent disease, to intervene in treatment, rehabilitation and health recovery (9; 62).” Despite this, there are few in which the word rehabilitation materializes as an area of ​​knowledge and professional performance. And even less, those who have some legislation about the objectives, training and performance of Rehabilitation Nursing. This is what rehabilitation nursing refers to nursing care aimed at the rehabilitation of people, therefore, care aimed at a therapeutic purpose in addition to the care itself.

“In the context of rehabilitation, the concept of care is omnipresent in the nurse's approach to the patient. This environment is conducive to caring individuals, and a humanistic approach to providing this care contributes to the promotion and preservation of human dignity ^{(1; 9)}. ”

A brief analysis of the countries with the specialty of rehabilitation nursing shows that it is not the population aging that determines its existence, nor the social development (here verified by the HDI), or even the time of creation of the profession. These are other reasons, which some articles partially highlight, but which, at a global level, need further study and evidence a gap in the knowledge of the history of the nursing profession.

According to several authors ^1,10-12, rehabilitation nursing is closely linked to the World Wars, when the objective was restorative so that wounded soldiers would be able to, or return to battle, or home. This statement is common in several studies, in numerous countries. Even the origin of modern nursing itself was in the care of soldiers wounded in war, in Crimea, in the middle of 1820. Initially, rehabilitation nursing was directed to the care of young and still productive people, with injuries and sequelae due to trauma.

The same fact did not happen in Portugal, whose reason for awakening the need for rehabilitation nursing arose from two events: firts, there was the case of Salazar chauffer (The Prime Minister), whose treatment was carried out in Germany; and second, the soldiers with consequences of the overseas war (Guinea, Angola, Mozambique, Timor, São Tomé and Príncipe and Cape Verde). After that, the Portuguese Government opened the first Rehabilitation Center in Portugal, in Lisbon, and the nurses responsible were to learn the specialty in the United States. Two nurses attended the specialty there and, when they returned, implemented in Portugal a specialization course in the area, along the lines of theoretical, theoretical-practical content and internships, as in effect until the present day. At the time, the intention of the course was to cover “all age groups with disabilities and imposed action initiated in the acute phase and continued in outpatient treatment in the community ^{(13; 13)}.”

The data show that the origin of rehabilitation nursing can be from England and the United States, which can be verified in the specialty distribution map. Despite this common origin, there are also some differences between countries, which will be dealt below.

England called disability nursing, instead of nursing rehabilitation, a fact that cannot go unnoticed, even if it is not deepened. The countries of England, Australia and New Zealand have a very important focus on nursing care for people with intellectual/cognitive disabilities, which is slightly different in Portugal, United States and Canada. In Canada and United States, there are many rehabilitation nursing companies focused on long-term home care. These differences and similarities must be investigated.

There is a consensus that rehabilitation nursing adds care to the intention of maximizing independence and functionality. In this sense, rehabilitation nursing pays attention to the other, inserting them into their daily lives, which is outside of the very place where care is performed. This is evident in the themes of professional meetings, which deal with the identity of this care and the relationship that must be established between professional and person for it to be carried out. Such relationship is essentially educational, as the professional shares with the subject being cared for, forms of this, being able to live in daily life with greater independence.

Gradually, the theme of chronicity and aging has emerged in the meetings, a fact justified by the change in the epidemiological and demographic profile. This will also determine changes in professional practice, which should adapt to this demand.

In general, the meetings reflect on the philosophy, principles, purposes and techniques of rehabilitation nursing, in addition to who is the patient to be cared for by the rehabilitation nurse and his participation in this process. Canada associates rehabilitation with parasports, which has not been seen in other countries. Two trends were also observed worldwide: the incipient discussion of the term autonomy, as the empowerment of the person to be rehabilitated, and the role of nurses in chronic diseases and aging. Both of them still have strong demarcation due to body functionality, which is contrary to the purpose of comprehensive care.

Regarding representative entities, the United States and Canada have similar entities, with a national organization and sections in each state. The relationship of the Portuguese Rehabilitation Association has a history of close proximity to the Ordem dos Enfermeiros (Nurses Order).

The Australian nursing code of ethics states that “The role of the nurse includes health promotion and maintenance and disease prevention for individuals with physical or mental illness, disability and/or rehabilitation needs, as well as the relief of pain and suffering in the end of life ^{(14: 1)}.” It is reiterated that in Australia the specialty is called disability nursing.

In the countries surveyed, it is the competence of nurses to care for the promotion, protection, recovery and rehabilitation. In those professionals who do not have the specialty of rehabilitation nursing, partial nursing care actions are carried out in rehabilitation centers, especially bladder and bowel reeducation for people with spinal cord injury and stump dressing for the amputees, in addition to general skin care on both. There was no evidence of differentiated nursing care actions in other people with disabilities (physical or intellectual/cognitive). They are always care actions, without the intention to rehabilitate.

In the United States, “Preparing for advanced rehabilitation nursing practice requires a graduate degree in nursing, preferably with a concentration on the concepts of rehabilitation nursing ^{(15; 2)}.” The same happens in all countries who have the specialty. In all, additional training is required for professional practice.

Countries that have the specialty work on the principle that rehabilitation nursing is a philosophy of care, and not a specific area where it should be performed. In this philosophy of care, there is the approach of different, but not excluding, aspects in the different countries, in which: Portugal establishes as one of the skills of the Rehabilitation Nurse “Promotes mobility, accessibility and social participation ³”, whose performance is strongly influenced, with the performance of rehabilitation nurses with government agencies for architectural and attitudinal accessibility. The United States establishes competencies in four axes: bed bound care, interprofessional work, successful promotion of life and leadership ¹⁶.

It should also be noted that the origin of rehabilitation nursing, as seen in the readings, is english (from England), especially in the countries colonized by them and North America (United States of America), in neighboring countries geographically. It is still necessary to deepen this statement and investigate which paths and, if, it really happened.

CONCLUSION

This article aimed to show a brief world overview of the specialty in rehabilitation nursing. It was noticed that although recent, the specialty is already consolidated in some countries, with systematic meetings between peers to reflect on the practice, the object of study, scope and objectives. There is a consensus of gaps in the field of knowledge, which are gradually filled with research and innovations in practice.

Even so, there are few countries with this specialty. Rehabilitation nursing has specific competencies, focused on nursing care with the intention that the cared subject can build alternatives to live with independence and autonomy. It has an interface with the work of several professionals in the area, including common actions and skills.

The challenge is, to collectively, unify the different movements, representative entities and practices, in order to reflect on the scope, purpose of the rehabilitation nurse's work and the necessary principles and actions, in order to build and collectively consolidate the specialty (at the level of countries that already have and those that do not yet have it). This is part of the recent demands for rehabilitation associated with chronic and degenerative diseases and communicable diseases, in addition to trauma.

APER, as a representative and strengthened entity of the specialty, plays an essential role in this articulation.

This study opened many gaps in the knowledge of the specialty's history, managing to answer a few proposed questions. Its limitations were that the existing material was scarce, which made it difficult to know countries whose language the authors are unaware of. On the other hand, it showed that the field of rehabilitation nursing is a field with specific performance and knowledge construction.