INTRODUCTION

People with disabilities are people using wheelchair, unable to walk or unable to travel long distances, with sensory difficulties (blind or deaf) and those who are temporarily disabled (pregnant women, children and the elderly). These people are confronted with environmental barriers that prevent their active and integral civic participation, and it is the State's obligation to guarantee and ensure their rights¹.

The International Classification of Functioning, Disability and Health (ICF) co-relate disability with functionality. It defines these as the result of a complex relationship between the individual's health condition (diseases, disorders and injuries) and personal factors (social, economic, literary), with external (environmental) factors that represent the circumstances in which the individual lives². People with disabilities are confronted with the problem of architectural barriers on a daily basis.

According to some authors, architectural barriers are present in different spaces and contexts and constitute obstacles, hindering or preventing the free movement of people experiencing a disability (transitory or permanent)³.

Accessibility, ranging from technical aids to access to buildings, is an essential condition for the full exercise of rights. Ensuring autonomy and access to existing goods and services in society for all has been the objective of adopted and updated legislation, as well as action plans by public and private entities, giving greater visibility to this cause in order to respect the rights people with mobility impairment and an inclusive society for all.

Currently, there are more than one billion people in the world who have some form of disability, and among these, 200 million have considerable functional difficulties⁴. Moreover, it is predicted that in Europe, in the year 2050, 22% of the population will be under 20 years old and around 40% will be over 65 years-old⁵. It is thus expected that there will be an increase in the population with restricted mobility in a global way.

According to the 2011 Census⁶, in Portugal it is estimated that there are 18% of people with limited mobility, with an increase in the prevalence of this population of 50% by 2050⁷.

The promotion and guarantee of full accessibility is essential to citizens’ quality of life of to the exercise of their rights as participating members of a community governed by the principles of a democratic society, in order to ensure their real participation and civic integration. Thus, accessibility translates into advantages for all: it allows the full exercise of citizenship and active participation in the various fields of activity of society; it ensures, to the greatest possible number of citizens, the possibility of living integrated in their community in situations of equal opportunities; contributes to the spaces and services providing conditions of safety and comfort; and ensures lesser burdens on autonomy and greater independence for all citizens⁸.

Taking into account the competences of Rehabilitation Nurse (RN), their importance in promoting inclusive environments becomes unquestionable. Thus, they should be involved in improving accessibility conditions, with a more proactive attitude in this area with a view to increasing the gains in quality of life for people with limited mobility. In partnership with local government authorities, they can "constitute a binomial of health promotion and architectural accessibility, since they are the political actors in the construction of inclusive territories, by complying with legal provisions, building inclusive cities for people with limited mobility”⁹.

The elimination of architectural barriers is essential so that people with limited mobility can have access to all systems and services in the community and thus enjoy their rights as citizens⁸.

Within this framework, it was considered relevant to reflect on the contribution of the RN in promoting accessibility and social inclusion, based on current accessibility legislation and policies, as well as the documents regulating the professional and theoretical practice nursing references.

To carry out this theoretical study, we focused on the legislation, programs, action plans and policies in force, on the specific competences of the RN, the quality standards of specialized care in rehabilitation nursing, and publications on this topic.

Although the environment, as a metaparadigmatic concept, is considered by the RN as a facilitating or hindering component in the adaptation of the person with mobility irmpairment, the existence of gaps in the intervention at this level, motivated this theoretical article. Following this reflection, in addition to highlighting the contribution of the RN, we intend to raise the awareness of these professionals for a sustained intervention in the scope of this issue, which is crucial for the quality of life and the exercise of citizenship of the person with mobility impairment.

DEVELOPMENT

In the Convention on the Rights of Persons with Disabilities (CRPD)¹⁰, disability is defined as an evolutionary concept that is not limited only to the limitations resulting from a pathological process. It also results from the interaction between these people and the behavioral and environmental barriers that prevent their full and effective participation in society, on equal terms with other people. Thus, the existence of architectural barriers accentuates the disability of any person with disabilities/limitations and increases their vulnerability.

The same convention¹⁰ emphasizes the universal principles of dignity, integrality and non-discrimination, defining the general obligations of governments regarding the mainstreaming of the various dimensions of disability in their policies. It also reaffirms the specific obligations related to making society awareness of disability, combating stereotypes and equal access for people with disabilities.

Thus, effective and appropriate measures must be taken to enable people with disabilities to “achieve and maintain a maximum degree of independence, full physical, mental, social and vocational ability and full inclusion and participation in all aspects of life” (Article 26 of CDPD). This same convention safeguards the right to live in an accessible physical environment (Article 9)¹⁰. In view of these rights of persons with disabilities, the second point of article 71 of the Constitution of the Portuguese Republic (CRP) reinforces the obligation of a “national policy of prevention and treatment, rehabilitation and integration of citizens with disabilities and support to their families” ¹¹.

It is essential to make people aware of the equality of rights, being a duty of the State the “promotion of the well-being and quality of the population and the real and legal-formal equality between all the Portuguese people” (paragraph d) of article 9 and article 13 of the CRP¹¹.

Regarding the issue of accessibility, the normative regulation through Decree-Law No. 123/97, aimed to introduce technical standards, in order to eliminate urban and architectural barriers in public buildings, collective facilities and public roads¹².

After the insufficiency of the solutions proposed by that diploma, the reffered Decree-Lawwas revoked¹², with the creation of a new diploma, which “defines the regime of accessibility to buildings and establishments that receive the public, public roads and buildings housing, aiming at the construction of a global, coherent and orderly system in relation to accessibility”, in order to provide people with limited mobility conditions equal to others. It is important to mention the extension of the scope of application of technical standards for accessibility to residential buildings (access to dwellings and their interiors), to ensure mobility without restrictions¹.

With the application of Decree-Law No. 163/06, it was expected that by February 2017, the deadline for the adaptation of spaces (buildings, establishments and equipment for public use whose construction date was prior to 1997), there would not exist architectural barriers in places of public use. However, the evidence demonstrates that architectural barriers still remain⁹.

Both at European and national level, strategies have been developed to promote architectural accessibility, which is implicit in one of the proposals of the XXI Constitutional Government, which includes the development of the program “Inclusive Territories” ³.

The European Union (EU) has developed actions to promote, for example, accessible tourism services, where we highlight the pioneering project in Portugal: Lousã - Accessible Tourism Destination¹³.

In order to improve mobility and accessibility for all, Portugal intends to combat this form of discitizenship by 2020 (Action Plan for Urban and Sustainable Mobility - PAMUS). Recognising the importance of knowledge about the needs of people with mobility impairments, the Portuguese Commission for Standardization in the field of Tourism (Subcommittee 8 - Accessible Tourism) validated a Guide to Good Practices for Accessibility in Hospitality with the aim of promoting quality in the accessibility of tourist services¹³.

The International Day of Persons with Disabilities is celebrated annually and in 2018, the theme was the Empowerment of Persons with Disabilities and the ensuring inclusion and equality. In this celebration visibility to the eleventh goal of the 2030 Agenda - 17 Sustainable Development Goals - inclusive, safe, resilient and sustainable cities and communities¹⁴. This consists of “providing access to safe, accessible, sustainable and affordable transport systems for all, improving road safety through the expansion of the public transport network, with special attention to the needs of vulnerable people, women, children, people with disabilities and the elderly; increase inclusive and sustainable urbanization and capacities for participatory, integrated and sustainable planning and management of housing conditions in all countries; provide universal access to safe, inclusive, accessible and green public spaces, particularly for women and children, the elderly people and people with disabilities”¹⁴.

The promotion of accessibility is fundamental for people's quality of life and essential for the exercise of equal rights for any member of a democratic society. In this way and as stated in Decree-Law No. 163/06, it contributes to “greater strengthening of social ties, to greater civic participation by all those who are part of it and, consequently, to a growing deepening of solidarity in the welfare state of law” ¹.

In this Decree-Law¹, it is also implied that the opening of establishments intended for the public, such as schools, health or commercial establishments, among others, is licensed by the competent authorities, when these comply with accessibility standards. Whenever there are non-conforming situations, which do not respect the required accessibility conditions, these must be mandatorily communicated to the competent authorities for licensing by the City Council, in order to be rejected.

Accessibility shoul be inclusive and universal, so that cities increasingly allow access by citizens, not only for the physical spaces they offer, but also for the public space that must be free from material obstacles.

A better quality of life for people with limited mobility is presented as a civic obligation of all citizens, in improving their responsibilities. Knowing that mobility difficulties affect a wide range of people, 60% in OECD countries¹⁵ are prevented from participating in economic, social and cultural life due to the presence of barriers, is has become urgent to adopt technical solutions that guarantee access to buildings, as well as to all public spaces and transport.

Local authorities play an important role in eliminating barriers, promoting an accessible environment free of architectural barriers, and should increase their performance and no longer limit themselves to the domains of infrastructure and basic equipment¹⁶. It is therefore essential to create and/or reinforce synergies between public and private entities and the health sector, in a binomial of health promotion and accessibility for people with limited mobility.

Most of the entities do not correspond to the real needs of their population. Public space, buildings and transportation are designed for the average man, of mature age, with strength and full health, according to Leonardo Da Vinci's theory.

Health professionals need to go beyond prevention strategies, promoting health, facilitating the well-being and environment balance, which since the mid-19th century until today, with Florence Nightingale's environmental theory, have being led by nursing¹⁷.

In the context of professional practice, the use of a theoretical nursing framework is essential to support and support nurses' performance, and should therefore be based on the best scientific evidence available¹⁸. Among the theoretical references, we verify that this science has been questioning itself about environmental issues for two centuries.

Evidence shows that Specialist Nurses in Rehabilitation Nursing identify Afaf Meleis, Dorothea Orem and Callista Roy´s conceptions as the ones that most support their practice¹⁹.

Nurses may become facilitators in the transition processes if their practice is centered on the person and their real needs²⁰. The transition to self-care dependence is a transformable factor through the improvement of the person's learning potential. Nurses can and should contribute significantly to both the promotion of self-care and the quality of the transition processes experienced by people, through continuous measures in which the multidisciplinary team should be focused and, where the RN can be an added value, being facilitator of this successful transition process.

Afaf Meleis' theory of transitions defends that individuals go through transitions during their life cycle, and that nurses should be able to recognize these moments and make them healthier²⁰. The resources of the community and society are determinants of the transition process and can be either facilitators or inhibitors. Therefore, it is up to the RN to promote the facilitators and to reduce or to eliminate the inhibitors, namely with regard to architectural barriers and the use of adaptive strategies that minimize them.

For Orem, the environment is one of the conditions that affects self-care, that is, all activities of daily living that are performed by the person to maintain their life and well-being²¹. The environment then refers to the external factors that affect self-care; encompasses physical, chemical and biological aspects encompassing the family, culture and community.

The person's ability to engage and adjust to self-care is called self-care action, which can be affected by basic conditioning factors (another concepts described by Orem), such as age, gender, development status, health status, environmental factors (existence of architectural barriers), sociocultural status, family-related aspects and availability and adequacy of resources.

Roy's conceptual model of adaptation defines the individual as an adaptive being, and the nurse's competence is to facilitate access to healthy adaptive responses²². This theoretical framework indicates that the stimulus is identified as the element that triggers the response, which may be intrinsic or extrinsic to the person, and includes all conditions, circumstances and influences around the person, or that interfere with the person's development or behavior. The term “environment”, in this reference, defines the set of stimuli that interact with the person. These stimuli can be divided into focal, contextual and residual²³.

The focal stimulus is the most relevant, as it directly confronts the person determining changes; the contextual stimulus is what comes from the person's internal or external environment, with a positive or negative influence on their situation, contributing to the behavior caused by the focal stimulus; and residual stimulus are internal or external environmental factors that have an undetermined effect on the person's behavior²².

Thus, we verified the relationship between the environment and the behavior of people in their daily lives, their involvement in the community and their social integration^21-22. Therefore, the contribution of theoretical references in the intervention of the RN towards the elimination of architectural barriers, fostering inclusive environments for people with limited mobility, is denoted.

Alongside the theoretical frameworks, nursing practice is supported by documents that regulate professional practice. Within the scope of the specialization in Rehabilitation Nursing, the regulation of the specific competences of the RN adds social inclusion to the health promotion already contemplated in the competences of the general care nurse.

In this context, accessibility is relevant within the scope of Specialized Care in Rehabilitation Nursing, being contemplated by the Regulation of Specific Competences of the Specialist Nurse in Rehabilitation Nursing, that states that this professional "enables peolple with a disability, activity limitation and/or restriction of participation for the reintegration and exercise of citizenship" and "promotes mobility, accessibility and social participation" through knowledge of specific legislation, awareness of the community to adopt inclusive practices, identification and elimination of architectural barriers, and may also issue technical-scientific opinions about the structures and social equipment of the community²⁴.

As described in the Regulation of Quality Standards for Specialized Care in Rehabilitation Nursing, it is the responsibility of RN to develop processes to promote the social inclusion of people with disabilities: “the optimisation of the resources of the customers, family and community to maintain and/or promote the inclusion of people with disabilities, promoting their participation in community life”; “the adoption of positive discrimination strategies for the most fragile customers”; “the involvement of the client, family and community in strategies promoting inclusion”; “the development of strategies promoting the active inclusion of people with disabilities, including housing conditions, improved access to employment, training and educational opportunities”; “the development of anti-stigma campaigns and activities in the media, schools, jobs, or other contexts, in order to promote the integration of people with special needs”²⁵.

The idea of ​​nurses as leaders of health promotion strategies has also been reinforced by the World Health Organization, which emphasizes the empowerment of nursing to achieve a health and well-being of the world population, through strategies to promote of physical, mental and well-being, coordinated by nurses who have scientific knowledge in their training capable of enabling them to carry out these strategies²⁶.

Some authors³ refer that the need for training on the theme of accessibility is recognized, being a potentiality to be considered by public and private entities. They also argue that the RN, given their technical and scientific knowledge, can raise awareness of the impact of architectural barriers on the quality of life of people with mobility impairments, barriers that can often be eliminated with simple measures and propper planning of resources.

The RN make a difference with regard to knowledge of the specific legislation for accessibility, knowing who to turn to if you need to request intervention to eliminate architectural barriers for people with limited mobility in the community, as well as knowledge of the activation process of the responsible means to eliminate architectural barriers. However, as confirmed by several authors⁹, these professionals do not differ from others in what concerns the development of some type of intervention in this regard, in their professional practice.

However, it is important to bear in mind that RNs are currently facing new challenges given the evolution of society, which is increasingly complex and multi-dimensional³.

Given the training and skills mentioned above, it is the responsibility of the RN to promote the development of strong health policies, influencing political, technical and social decisions to promote accessible environments, particularly by raising awareness and training of mayors on the relevance of the elimination of architectural barriers and for respecting and valuing human diversity, for a full social participation of people with mobility impairment. In this context, public and private entities are decisive for the construction of inclusive territories for these people.

One of the RN's interventions, in line with current health policies, is its contribution to increasing the health literacy of the population and, in this specific case, of people with limited mobility and their family caregivers. The greater the knowledge they have regarding their health status and existing resources in the community, the greater their autonomy, self-management of the disease, self-efficacy, assertive use of health services and empowerment²⁷.

Since one of the main objectives of nursing is to obtain gains in the person's health, an increase in literacy is essential, as it is associated both directly and indirectly with a higher health outcome²⁸.

The empowerment of the person with limited mobility corroborates the centralization of the person, making them responsible for the health care they receive and for the identification of hindering conditions in their daily lives and for the promotion of inclusive policies. The person with limited mobility can be a passive or active agent, and their active participation is important, placing them at the level of political decision-making, an aspect that should be driven by the RN.

CONCLUSION

Although there is still a significant opportunity for improvement, the theme of accessibility has been playing an increasingly relevant role in the RN's performance in the scope of public and private entities, as a result of an increasingly visible awareness.

Barriers to accessibility undermine equal opportunities, favor discrimination, accentuate prejudice and increase disability, aspects that are more than sufficient to require a systematic intervention from professionals.

The promotion of accessibility is a fundamental element in people's quality of life, being an essential means for exercising of the rights that are conferred to any member of a democratic society, an aspect that reinforces, once again, the need for RN to consider this component within the scope of the design and provision of rehabilitation nursing care.

in order to improvement of accessibility, decision-making centered on the nursing process that demonstrates a holistic and potentially empowering look is crucial for the person with limited mobility and their family caregiver, the community and stakeholders, and particularly for specialist nurses in rehabilitation nursing.

As knowledgeable about the laws and the rehabilitation process, the RN should also intervene in order to increase the literacy of people with disabilities and their families about their condition, in order to promote their autonomy and independence. The empowerment of people with disabilities has become the motto.

Nursing as a scientific discipline targets not only the person, but also the family, the community or the society. Therefore, the RN is the driver and the driver for the integration of the person in their environment, intervening in their autonomy and adaptation to the environment, so that their limitations do not impede the exercise of citizenship.

This theoretical article is relevant, objectively framing the contribution of the RN as preponderant agents and active participants, both in the political-social decision-making process and in facilitating access to healthy adaptive responses of the person with mobility impairments.

In the future, taking into account that this theme will have even greater relevance, it should be given greater value in the training of the RN and the remaining actors, analyzing its contribution to the definition of social policies and the adaptive outcome of the person with conditioned mobility in all their contexts.