Study Design

The qualitative nature of the study allows improving knowledge in nursing in the particularity of empirical, aesthetic, personal and moral knowledge ⁶, which appears in the participants' speeches as authors of the experience of being and caring in rehabilitation nursing and was designed through a case study. We consider the study to have case characteristics, since all participants are from the same service and the problem under analysis is the centrality of management and assistance in a PMR service.

Taking into account the starting question, we formulated the following research questions: What is the perception of specialist nurses in rehabilitation nursing about the structural component of the service for the development of their activity?; What is the perception of specialist nurses in rehabilitation nursing about the facilitating factors of the structure for providing care in a Physical Medicine and Rehabilitation unit?; What is the perception of specialist nurses in rehabilitation nursing about the factors that complicate the structure for providing care in a Physical Medicine and Rehabilitation unit?.

Given the nature of the study, we used a non-probabilistic convenience sample of RN with the inclusion criterion of being RN working in an PMR service. In this study, 16 RNs participated, which corresponds to all those who exercise functions in the service during the data collection period, whose characteristics we will describe.

Data collection and data analysis instruments

The data collection instrument used was a semi-structured face-to-face interview. The interview guide consisted of eight open questions and a set of eight questions for the sociodemographic and professional characterization of the participants. It was not entirely open, nor involved a rigid set of questions, the use of the semi-structured interview allowed, through the interaction between the interviewee/interviewer, the emergence of questions and data that, not having been previously considered, contributed to the enrichment of the collected information. The recording of the interviews was carried out through audio recording, after authorization from the participants. In order to guarantee anonymity, all interviews were coded with the initial letters of the words Nurses and Rehabilitation, followed by the number: ER1, ER2, ER3, etc.

The data analysis base was framed in the perspective of Bardin (2009). The content analysis proposed by the author is composed of a set of communication analysis techniques, a systematic and objective methodology that is developed in stages: pre-analysis, material exploration and, finally, the inference and interpretation of results obtained ⁷. After validating the content of the interviews by each participant, we created 16 documents constituting the analysis corpus that were later submitted to the Atlas.ti 22 software, designed for qualitative data analysis. The whole exploration of the expressions of the participants was coded by two separate researchers, followed by a moment of conciliation of the categories that did not coincide between the two, where the meaning of the expressions was defined from the definitions developed by the researchers.

Ethical considerations

After planning the study, it was submitted to the ethics committee of the hospital institution, with a favorable opinion expressed in Nº 51/22 (we did not identify the hospital institution to guarantee the confidentiality of the data). To guarantee the reliability of the data obtained, the recording of the interviews was carried out through audio recording, after informed consent. The meeting with the participants was confirmed in advance through telephone contact, according to the availability of each participant. The interviews took place between March 2022 and June 2022, in a reserved space at the hospital institution.

People management and service leadership

The management of people and leadership has a preponderant role in the organizations, becoming fundamental in the competitiveness and in the changes of the services.

Once the identified associations were clarified, it is important to highlight that from the analysis of the participants' speeches, within the scope of the structure dimension, two categories emerged: people management and leadership in the service and the physical environment and conditions for the functioning of nursing practices. It should be noted that in the speeches these categories emerge in an intimate interaction between them, as shown in the following diagram (Diagram nº2).

Diagram nº 2 Structure dimension categories 

In the people management and service leadership category, the participants argue that nurses with management functions should promote more moments of reflection on the practice “(...) the ideal would be to have time, and I am not talking about our own time, service time to be able to reflect on what we do. When we invest in any training it is with our personal time and I think that a different modality should be introduced in our daily lives, which would be for us to be able to evolve theoretically and in practice and these aspects are more balanced” (ER4).

Reflection on practice has been highlighted by several authors as an excellent strategy to improve the quality of care, namely Stonehouse, who mentions that finding time to stop and think is often impossible, however, reflective practice beyond of qualifying the decision-making process, it promotes the achievement of more positive results for the team and mainly for the clients ⁹. Any decision-making process can be improved, and the truth is that in the professional context, the positive points need to be recognized and valued, particularly by nurse managers.

As another participant reinforces, “there are things that I would like to see different here in this service, it is a service with a lot of potential, that we could do many things, that we could reflect more on the practice (...)” (ER13). In the same vein, other authors consider that reflection on practice is considered a key skill in the professional development of nurses, allowing them to become more self-aware and, consequently, improve the provision of care ¹⁰.

Most participants, due to the type of service, mention that their post-graduate training is recognized, especially regarding the opportunity to provide care within the scope of specialization in rehabilitation nursing “I was given the opportunity and, therefore, the focus of my work is the training of activities of daily living, I am a specialist nurse in rehabilitation nursing” (ER7), and in the same line of thought, they add “I perform everything related to general care and specialty nursing ( ...) (ER1). Regarding this finding, in Santos' perspective, it is effectively up to the manager nurse to coordinate, promote and increase measures and create conditions for the RN to assume themselves as reference nurses, especially in the case of patients with significant self-care needs ¹¹.

The participants themselves value their postgraduate training in the context of professional practice, stating that “(...) our training is very complete, sometimes we may just have to look for some information to remember certain things” (ER2), but the truth is that “We have more training and are more aware of what we need to do.” (ER5). Postgraduate training in the area of rehabilitation nursing is of particular importance, as it makes it possible to deepen knowledge and develop essential skills to respond to health challenges. Currently, the intervention of the RN is clear and is explicit in health outcomes and people's satisfaction ¹².

Participants representatively valued moments of reflection on the practice and recognition of nurses' training. Moments of reflection on practice contribute significantly to the quality of care but require time available for discussion. On the other hand, the recognition of training becomes an act of valuing formal and informal training, in the words of the participants.

Physical environment and conditions for the functioning of nursing practices

In the category physical environment and conditions for the functioning of nursing practices, four sub-categories emerged from the participants' speeches: available space in the service, staffing and specialist nurse/patient ratio, continuous and in-service training and work methodology.

Participants refer that the space available in the service is adequate to the needs of patients, remembering that “the service was created from scratch, albeit with some limitations (...) but from the outset it is a service that has a different type of attention. The fact that we have more bathrooms, the wards have only two beds (...) the service is adapted for patients and for our rehabilitation nursing practice, which is a process that facilitates our work” (ER1).

The sensitivity of the RN to environmental issues has already been addressed by other authors, namely Pereira and collaborators, who highlighted that the RN’s aim, in their specialized practice, to promote well-being and quality of life, developing at the same time maximize the health potential of people with disabilities by promoting mobility and accessibility, which effectively requires environmental conditions ¹³. In this context, other authors addressing the competences of the RN, praise their role in promoting more inclusive environments, and their involvement in improving accessibility conditions should exist ¹⁴. Although this involvement is fundamental, in the context in which the person lives, it must be a reality in each service where specialized rehabilitation care is provided, not least because without these structural conditions, it will be difficult to instruct and train strategies that promote the qualification of people to the self-care.

Environmental issues are decisive for the care provided by professionals, but essential for people who need their care. What is certain is that, as one participant stresses, “compared to other services, our physical structure is minimally adapted for this type of patient.” (ER15). Even so, other participants recognize opportunities for improvement “We have a physical structure that allows us to work with patients, but for example the bathrooms and shower spaces should be bigger, and the showers be equipped with mirrors. The wards have two beds, which is very good, but if they only had one, it would be better to simulate the patient's house.” (ER14).

Usually the common concept of structure focuses on the physical environment and material resources, but as Donabedian points out, human resources are also part of the structure ⁴. The participants, in the area of physical conditions, pointed to the space available in the service as a favorable condition for the development of care, however, they point out as suggestions for improvement: the need to equip the shower spaces with mirrors. It is necessary that environments meet accessibility conditions in order to respond to the needs of each individual, so that their total integration occurs, without any difficulty ¹³. In the PMR service, the participants report having good conditions, however, it will be necessary to think about them in terms of the interface with the patient's reality, in their home, for the training that begins in hospitalization.

As for staffing and the specialist nurse/client ratio, the participants considered it appropriate, stating that “In this service we have good ratios, in terms of nurses as assistants (…) mainly in the morning shift, (…) it helps us to have more time to provide care”. care for patients and care more calmly (...) give patients time to do things, in other services this no longer happens because they have fewer people working.” (ER2). This reality is not frequent in other contexts, with several authors actually mentioning ratios that are out of line with the needs of people in nursing care and, especially in specific rehabilitation. In an investigation carried out in Portugal on the environments of nursing practice, it was found that the perception of quality was unfavorable in most Portuguese hospitals, namely the dimension of human resources was one of the most critical quality components ¹⁵.

In the context of rehabilitation nursing care, there is no adequacy of human resources in health organizations ¹⁴, contrary to what one of the participants states, who considers “(...) from the point of view of staffing, we are not bad ( …) I even think we are doing very well in terms of ratios. (ER4).

The participants consider that the ratios have an impact both on the quality of care and on promoting the patient's autonomy. As a result of the concern to provide care in a partially compensatory pattern and with a view to evolving towards a support/education pattern, the RN recognize the value of the time they can spend with each patient “we have a very good ratio that allows us to spend the time with the patient time he needs, namely in promoting autonomy in self-care” (ER14). In the provision of care, the Order of Nurses in Regulation No. 743/2019, defined the appropriate number of nurses in each work context, thus promoting favorable rates of quality and safety of care. In specialized centers and internment services for MFR, they must have 75% of RN, having to guarantee that at least one RN remains 24 hours a day ¹⁶.

The complexities associated with health care, specifically nursing and rehabilitation nursing care, require adequate staffing to ensure safety and quality in different contexts, as is the case of the PMR. The concept of safe staffing in nursing is dynamic and comprehensive, where the number of nurses is considered and their skills are valued, in order to guarantee the provision of safe care. This means that it is not only the number that is at stake, but also the skills, experience, training and motivation ¹⁷. Most study participants refer to staffing only in the sense of the specialist nurse/patient ratio, with good ratios for the assistance required in the service being predominant, but they warn of the need for more time to provide care, in order to guarantee time for the patient to develop independence and autonomy.

With regard to in-service training, the participants state that it can make an important contribution to the organization and guidance of nursing practice “I think there should be more in-service training, because then we end up investing more in training or congresses. We should plan in-service training throughout the year” (ER5), not least because, as one participant mentions, “in-service training in recent years has been completely reduced (...)” (ER9). The contribution of in-service training to nursing practice allows theoretical knowledge to be contextualized in solving real problems in the practice of nursing care. In this sense, and through in-service training, organizations can create reflective environments, for team learning, which promote professional autonomy, as well as intercommunication between all stakeholders ¹⁸.

Continuous and in-service training takes paths that range from informal training to formal training, including self-training with emphasis on the job, which effectively becomes a unit within the pillar of the structure. All participants embodied the subcategory continuous and in-service training, bringing to the discussion its importance in guaranteeing a structure adequate to quality, from the person's own investment, outdoor training (conferences, workshops) and indoor training (in-service), in addition to the current ease of the e-learning methodology. The weakness identified by the participants is the lack of an in-service training plan, considering the specificity of the care and techniques developed in the PMR services. Given the contributions of in-service training to guarantee the quality of care, it is necessary to adopt strategies that allow reflections on practice, with an impact on the design and delivery of nursing care ²⁰.

As for the work methodology, the opinions among the participants differ, with some considering that the methodology adopted in the service - reference nurse - is a facilitating aspect of promoting the quality of care, however, they point out that this method has already been more efficient and complete , “We should follow the reference nurse method as it used to be, that (…) we had home visits and meetings with the family, we should take this further (…)” (ER1). As one participant clarifies, “We have the reference nurse method, which at the moment is only based on updating the patient's care plan assigned to us” (ER3). The reference nursing method is internationally recognized, it consists of a strategy of individualized responsibility in decision-making, in relation to nursing care ²¹.

For some participants, the reference nurse method remains the most appropriate “We have the reference nurse method (...) which allows us to have a view of the patient, because each nurse is associated with a patient, and, although not we always stay with that patient, we assess the patient and manage the care plan” (ER8).

On the other hand, some participants consider the reference nurse method a difficult aspect, “In this service I do not consider the reference nurse method the most appropriate, sometimes with the distribution I can spend more than two weeks without being with my patient reference and then I practically don't know him, (...) now if they ask me what would be the most appropriate method, I think we would have to reflect on that” (ER13). In this follow-up, two participants chose the individual method as a guide for their professional practice, “I think we should have an individual method of work” (ER6), “In my perspective, the method of work should be mostly individual so that each nurse is responsible for everything that concerns its users” (ER10).

In the scientific community, the work methodology has been the subject of discussion, however, it is certain that this is an integral part of the nurses' work process. The selection of a nursing work method reflects the type of conceptualization, organization and provision of care in a given context. And for that reason, they translate a perspective, a way of thinking and organizing nursing practice ²².

It should be noted that the RN, in the organization of work, may adopt various methods, in order to respond to the complexity and differentiation of care. However, given the specific skills of these professionals, the choice of reference nurse and/or case manager methods will be effectively the most relevant, in terms of satisfying people's real needs ²³.

The Nursing Order recognizes the need to organize nursing care with an emphasis on the use of methodologies that promote quality and safety, allowing an integrated response to patients' problems. Participants are divided in their opinion between the reference nurse method and the individual method, emphasizing the need to particularly improve the daily distribution strategy ²⁴.

Let us remember that in the work methodology, the most mentioned method is the reference nurse method, also referred to as responsible nurse or Primary Nursing. Nurses are assigned one or more patients and are responsible for planning, executing and evaluating care, from admission to discharge, whenever they are on duty. The fragility identified by the participants is related to the lack of respect for the maintenance of the dyad, responsible nurse/patient, when the work is distributed, which conflicts with the design of the method. The method foresees that the services will have two types of nurses, the reference and the adjuncts/associates, which will facilitate the distribution of patients in the absence of the reference nurse. This method values the nurse's responsibility considering that the reference nurse, in addition to being responsible for the patient, coordinates and supervises care throughout the hospitalization ^21,22.

In opposition to the methodological practices of the organization of care, where the use of the reference nurse method is mentioned, participants appear to defend the individual method, which consists of a care approach to the patient as a whole, where the nurse assumes daily responsibility for care for all distributed patient care ²¹. Recently, some studies have emerged that demonstrate associated weaknesses, considering that the nurse's responsibility is limited to the work shift in which the patient is distributed ²².

Rehabilitation nursing can mean a philosophy of care based on rehabilitative and recovery principles, which implies skills on the part of nurses to intervene in functional, psychological, educational and social terms. With the aim of seeking health, independence in self-care and adapting to healthy lifestyles, well-being and quality of life, it requires knowledge that goes beyond promoting self-care, as it involves the person as a whole, reasons that make this area of intervention a differentiating specialty from others ²⁵. The particularity of this study constitutes the analysis of the structure in order to guarantee conditions for the achievement of the process and thus demonstrate the results of assistance in the PMR service.