INTRODUCTION

In most developed countries, rehabilitation is part of the care provided to people in critical situations, and its importance is particularly recognized in early mobilization, a safe and beneficial practice that should be a priority in this context.¹

As a rule, mobilization and other rehabilitation techniques are mostly carried out by physiotherapists integrated into the team or on call, depending on the country under analysis. ^2,3 In Portuguese intensive care units, physiotherapy is mostly carried out on call by the intensive care physician, however nurses with specialized training in rehabilitation, commonly referred to as rehabilitation nurse (RN), also take part in the rehabilitation process.⁴ This specialization in nursing emerged in Portugal in the 60’^s based on the North American model. Initially, specialists were trained for the Alcoitão Physical Medicine and Rehabilitation Center and later, the increase in the number of RNs allowed them to integrate rehabilitation or respiratory kinesitherapy services and also to integrate primary health care and hospital services, without having a homogeneous distribution based on the needs of this specialized care. ⁵

According to the Order of Nurses, “the rehabilitation nurse designs, implements and monitors differentiated rehabilitation nursing plans, based on people's real and potential problems. (…) their intervention aims (…) to ensure the maintenance of the clients' functional capacities, to prevent complications and avoid disabilities, as well as to provide therapeutic interventions aimed at improving residual functions, maintaining or regaining independence in life activities (…)”. The rehabilitation nursing specialist intervenes above all “at the level of neurological, respiratory, cardiac, orthopedic functions”⁶, fitting into what the critically ill patient's rehabilitation care needs will be.^7-9

These nurses are dispersed throughout almost all units, even though, due to lack of resources or management options, they do not always perform functions within the area of ​​specialization. Even so, we can find RNs integrated in the multidisciplinary team of ICUs or integrated in specialized teams that go to the units to provide rehabilitation care, as part of a heterogeneous organization based on 3 base models: ⁴

In this context, the RN is present in all units that use the internal model and in about 19% of the specialized external teams that provide rehabilitation care to critically ill patients. ⁴

In this issue, we intend to analyze this information in more detail in order to understand the importance of Rehabilitation Nursing in Portuguese Intensive Care Units. The research question asked was: What is the importance of rehabilitation nurses in the care of critically ill patient, adult, in Portugal? The specific objectives of this work are:

METHODS

It is a secondary analysis of the national survey to assess the organization of rehabilitation care in Portuguese intensive care units. The study was conducted between November 2016 and March 2017, through an online survey of Head Nurses or Responsible Nurses of the 58 adult ICU's that integrate the Portuguese Society of Intensive Care database. The survey consisted on a total of 28 questions, grouped into: institution characterization, unit characterization, team characterization, rehabilitation care organization, availability of resources and results.⁴

Statistical analysis was performed using the program IBM SPSS Statistics version 22. Regarding descriptive statistics, frequencies, percentages, means and standard deviations were calculated.

The Chi-Square test was used to compare the distribution of the number of RNs according to the different models of organization of rehabilitation care and to compare the assessment of physical condition at discharge between ICUs with and without RNs.

The comparison of care results was performed using the Mann-Withney test for independent samples.

A significance level of 0.05 was used.

Study approved by the Ethics Committee of the University of Beira Interior (Opinion CE-FCS-2016-028).

RESULTS

Forty-eight valid surveys were obtained for 42 medical-surgical or multipurpose units, 3 neurosurgical units and 2 cardiothoracic units (1 survey does not mention the type of unit). These units represent a total of 399 intensive care beds and 132 intermediate care beds.

Availability of nurses trained in rehabilitation

A unit integrates in its team, on average, 31.6 ± 14.7 nurses, of which around 9.6% have specialized training in rehabilitation nursing. These ICUs include a total of 140 nurses with this type of specialization, on average 2.9 ± 1.8 nurses per unit.

• - 93.8% of units have nurses with specialized training in rehabilitation in their team;

• - 75.0% of the units have nurses with specialized training in rehabilitation in specialized functions;

• - 45.8% of the units have nurses with specialized training in rehabilitation that are performing full-time specialized functions.

In absolute terms, 60% of nurses with specialized training perform specialized functions, 26.4% full-time and 33.6% part-time (graphic 1).

Graphic 1 Time to perform specialized functions. 

Analyzing the distribution of the number of RNs according to the different models of organization of rehabilitation care (Table 1), we find that, in average terms, it is in the mixed model (articulation of the rehabilitation care provided by the ICU team with specialized external teams) that there is a greater number of nurses with specialized training in rehabilitation per ICU (3.6 ± 2.0 nurses/unit). In contrast, units where rehabilitation care is provided by external teams are those that have fewer RNs in their team (1.58 ± 1.17).

In addition to the RNs integrated in the intensive care teams, in 10 units (about 17%) these professionals are part of the external teams that provide rehabilitation care in these services.

Participation in the mobilization and entry of patients

In addition to the rehabilitation activities carried out in bed, the RNs, regardless of the model of organization of rehabilitation care, are generally the promoters of the mobilization of patients out of bed (Graphic 2) and actively participate in this procedure, usually in conjunction with the caregiver nurse (Graphic 3).

Graphic 2 How the decision to mobilize patients out of bed is made 

Graphic 3 Elements that usually participate in the mobilization of patients out of bed 

DISCUSSION

Nurses with a specialization in rehabilitation nursing are present in most of national ICUs, an unparalleled situation internationally¹⁰. In addition to the work they develop with patients, taking the initiative to start the rehabilitation process early and developing a appropriate plan to the patient's condition, ⁴ these professionals promote, as evidenced in this analysis, the mobilization of patients out of bed, meeting the guidelines that advocate early mobilization of these patients.¹¹

In addition to the clinical work, research projects are developed in specific areas of rehabilitation for critically ill patients, namely at the respiratory level, ^12-16 motor ¹⁷ and also in the promotion of autonomy¹⁸ and in the competences to care for the person with dependence on self-care¹⁹. This development seems to be closely related to the creation of a master's courses in rehabilitation nursing, since most of the investigations were carried out in this context.

Although this article presents some traces of what is the intervention of rehabilitation nursing in intensive care units, we are convinced that we only present the tip of the iceberg and that researches in this area has high potential. It would be interesting to know in fact how early mobilization is and whether we comply with international recommendations, which has not always been seen in researches carried out in other countries.^20-22 In this particular aspect, rehabilitation nursing could strengthen its position, as it is a sensitive context in which it is essential to master a set of very specific competences within the reach of the RNs. This statement also goes through the documentation of the practice and the indicators are the best tool. The Order of Nurses and the Rehabilitation Nursing Specialty College have already taken some steps in this direction, disclosing a set of indicators that are potentially sensitive to rehabilitation care.²³ Those that are most suitable and possibly complemented with some more indicators must be identified to this context.^24-26 In order to develop this work, it will be important to increase the participation of RNs in the assessment of the physical condition of patients at discharge and post-discharge, and to monetize the 40% of nurses with specialized training who at that time did not perform functions in the area.

CONCLUSION

Nurses with a specialty in rehabilitation nursing are present in most national ICUs and constitute an important element in the care of critically ill patients, a unique situation in the international context. Its intervention involves developing individual care plans, including out-of-bed mobilization, and its activity is supported by a growing scientific production. At this moment, we do not have data that allow us to infer about the influence on care outcomes, in general, or more specifically on functionality or gains in self-care, targets of intervention in this specialty.