INTRODUCTION

Aging resulting from the increase in average life expectancy and acute disease situations often lead to the loss of the user's functional capacity.

The Self-Care Deficit Nursing Theory, developed by Dorothea Orem, defines self-care as a regulatory human function, that is, an action taken by people voluntarily to regulate their own functioning and development, actions that ensure the provision of necessary requirements. to the functioning of the organism .

According to the International Classification for Nursing Practice (CIPE), self-care is a self-performing activity: taking care of what is needed to maintain oneself, ensure survival and deal with basic, individual and essential needs and activities of daily living . Self-care concerns the practice of activities that individuals initiate for their own benefit, to maintain life, health and well-being .

It is important to emphasize the differences between the concepts of autonomy, dependence and independence. Autonomy is the individual ability to decide and command their actions . It is the ability and/or right of a person to choose for himself the rules of his conduct.

Dependence means a state in which a person is unable to exist satisfactorily without the help of another. On the contrary, independence is the ability to carry out activities without help from another person . It is the ability to satisfy your own needs independently.

The monitoring of health gains is a very current topic and acquires particular importance when talking about continuous quality improvement strategies, assessment of the level of user satisfaction and the results obtained. Monitoring is therefore evaluating the quality of health care.

Home is the privileged place for providing care to users, as it provides the possibility to assess and intervene on family, sociocultural and economic factors that influence the context and outcome of nursing care . It is also in this context that functional capacity is best evaluated, since the person is confronted with their day-to-day reality, which allows rehabilitation to take place with a greater degree of adaptation to the user's reality.

The integrated continuous care team (ECCI) is a multidisciplinary team under the responsibility of primary health care and social support entities for the provision of home services, resulting from comprehensive assessment, medical, nursing, rehabilitation and support social assistance, or others, to people in a situation of functional dependence, terminal illness or in the process of convalescence, with a social support network, whose situation does not require hospitalization, but who cannot travel autonomously (6 ⁾ .

The Specialist Nurse in Rehabilitation Nursing (EEER) has a key role in establishing strategies to overcome the constraints that affect functionality .

The EEER has specialized knowledge and skills that allow it to plan, implement and manage rehabilitation programs, in which the person and family are the protagonists in the reconstruction of their life path and health process. It is up to the EEER to monitor the implementation and results of rehabilitation programs, evaluating and making the necessary adjustments in the process of providing care, which allow it to analyze the effectiveness of its intervention, in order to be able to transmit gains in health sensitive to rehabilitation nursing care , promoting safer and more effective practices with the person and family .

It was decided to carry out a study whose general problem is the evolution of functionality in a home context, trying to obtain an answer to the starting question: “What is the evolution of functional independence, resulting from the provision of care by the rehabilitation nurse, in a home context? domicile?”.

In order to answer the stated research question, we outlined the following objectives: to analyze the evolution of the user from admission to the moment of discharge from the ECCI, the level of physical dependence, namely for the following activities of daily living (ADL): feeding, personal hygiene, urinating, defecating, movement, mobility, toilet, dressing, bathing and going up/down stairs; to identify the contributions of interventions by rehabilitation nurses to gains in the user's functional independence and to compare the evolution of users through some attribute variables.

This study led to reflection on the effectiveness of providing rehabilitation nursing care in terms of promoting gains in the user's functional independence in the home context. We think that the present study can contribute to the improvement of the provision of rehabilitation nursing care and to the identification of possible existing gaps in this.

METHODOLOGY

We developed a descriptive, retrospective study that aimed to evaluate the functional evolution of the user from the moment of admission to discharge in an ECCI of the Agrupamento de Centros de Saúde (ACeS) of Baixo Vouga, in order to understand whether the care provided by the rehabilitation nurse in home environment contribute to the decrease of the user's degree of dependency and consequently represent gains in functionality.

We analyzed the Rehabilitation Nursing records, referring to users referred for continuity of rehabilitation care, for the ECCI in which the study took place, from January 2015 to December 2019.

We use manual processes, the GestCare application of the National Network for Integrated Continuous Care (RNCCI) and the S-Clinic Information System, for the selected users. We built the instruments for operationalizing the variables under study that we later used. Data collection was based on the construction of a registration grid which contained sociodemographic data, cause of request, diagnosis and the instrument for assessing the degree of dependence - Barthel Index, assessed at admission and at discharge from the ECCI. A non-random and intentional sampling was chosen.

We defined the following inclusion criteria: the user having been referred for rehabilitation nursing care at the selected ECCI and hospitalization equal to or greater than eight days. As an exclusion criterion we defined: hospital stay equal to or less than seven days.

The intervention of the EEER consisted of carrying out home rehabilitation interventions three times a week during the entire period in which each user was hospitalized. Rehabilitation plans were implemented with a focus on teaching, instruction and training in ADL, balance, muscle strength and gait. The informal caregiver was present during the home visits in order to receive education and instruction in the aforementioned areas, also contributing to the continuity of care.

In the descriptive statistical analysis, we used absolute (n) and relative (%) frequencies; measures of central tendency: mean (M); dispersion measures: minimum (Min), maximum (Max) and standard deviation (SD). The significance level for the statistical treatment was 5% (p≤0.05%). In the inferential analysis, the Wilcoxon test for paired samples and the t test were used .

Data collection was authorized by the Board of Directors and the Ethics Committee for Health of the Centro Regional Health Administration - opinion 003389/04.02.2014 and respective addendum of 09.01.2020. The study was conducted in accordance with the required ethical and legal standards. Informed consent was given to all participants.

RESULTS

The sample consisted of 63 users, who were accompanied by rehabilitation nurses, and who were between 56 and 104 years old. The mean age was 78 years old (m=78.41; sd=10.28), and the most frequently found age was 80 years old.

With regard to gender, it was found that the users were mostly female (76.2%; n=48), and the vast majority of the elements were married/or lived in a de facto union (52.4%; n =33) or widowed (42.9%; n=27). There were 3 single users (4.7%).

The main reason for requesting rehabilitation nursing intervention was the traumatic/orthopedic area ( 60.3%; n=38) , followed by the non-traumatic/medical area (27.0%; n=17), the neurological (9.5%; n=6) and finally the respiratory area (3.2%; n=2). With regard to the main diagnosis, it could be stated that the request for rehabilitation nursing intervention was due in most cases to the diagnosis of femur fracture and subsequent placement of total hip prosthesis (38.1%; n=24) , also highlighting the presence of Immobility Syndrome (27.0%; n=17); the diagnosis of coxarthrosis (9.5%; n=6), the diagnosis of Gonarthrosis and the diagnosis of Cerebral Vascular Accident (CVA) (6.3%; n=4 each).

Next, the results obtained in activities of daily living in the two moments of evaluation analyzed will be presented. Thus, in the subsequent table it was verified that in the initial evaluation most of the users were independent in feeding themselves (more precisely 68.3%; n=43), but the percentage of independent elements in feeding increased to 81.0% (n=51). In the same way, also in the personal hygiene activity, the percentage of independent users increased from 36.52% (n=23) to 81.0% (n=51) in the first evaluation for the assessment of capacities after the nursing intervention of rehabilitation.

In elimination activities, namely urinating, it was found that in the initial assessment most users were already continent (68.3%; n=43), with this percentage slightly increasing to 76.2% (n=48) in the final evaluation. With regard to defecating, the number of elements without problems remained from the initial to the final evaluation (81.0%; n=51), with a decrease in incontinent elements from 11.1% (n=7) to 6.3% (n=4).

In turn, and with regard to displacement, it was observed that initially few elements were able to move independently (9.5%; n=6) and the highest percentage was unable to move (42.9 %; n=27). However, in the final evaluation, 66.6% of the users already showed the ability to move without any help (n=42) and only 17.5% (n=11) remained unable to move. In mobility, the appearance of independent elements was not so visible, although the value of 39.7% (n=25) acquired the ability to walk without any help and it was found that the number of users totally immobilized from 38.1 decreased % (n=24) to 17.5% (n=11).

In the use of the WC, the percentage change was quite expressive. In the initial assessment, only 22.2% (n=14) were independent in using the equipment, while in the final assessment the percentage of independent users in this activity was 66.6% (n=42). Also in the ability to get dressed, the percentage of totally dependent users decreased from 31.7% (n=20) to 9.5% (n=6), and the percentage of 58.7% (n=37) that became independent in this task.

With regard to the bath, it could be stated that in the first evaluation almost all elements were dependent before the rehabilitation nursing intervention (98.4%; n=62), but after the intervention the percentage of 42.9% ( n=27) was able to take a shower without any help. Finally, with regard to going up and down stairs, the number of disabled users decreased from 68.3% (n=43) to 3.2% (n=2) and the figure corresponding to 41.3% (n= 26) who, in the final evaluation, were independent in going up and down stairs.

Through the previous table it was possible to verify that there was a percentage change at the level of all evaluated activities. Thus, and in order to verify whether there is a significant difference between the two assessments, the Wilcoxon test was used to test the difference between the means obtained in the initial assessment and the final assessment.

Thus, it was found that a significant difference could be assumed in almost all activities of daily living, except in the elimination activities in which the difference was not statistically significant. Based on the results, it was possible to state that the levels of independence were clearly higher in the final evaluation (discharge time), after the rehabilitation nursing intervention, since it was possible to verify that the average was always higher in the final evaluation, depending on the situation. in table 2.

Just as it was found that there is a significant difference in almost all activities of daily living, it was also verified whether this difference extends equally to the total level of independence. Table 3 confirms that in the initial assessment the average found is 47.14 ( sd =25.27) having increased to 74.86 ( sd =30.92) in the final assessment. This difference was considered statistically significant (t=-14,000; p <0,000), which indicated that the level of functional independence of the studied users increased considerably after the rehabilitation intervention.

By confirming the data obtained previously through the percentage comparison between the various levels of dependence, it was observed that in the initial evaluation the equivalent of 20.6% (n=13) presented total dependence, the value of 44.4% (n=28 ) showed severe dependence and 34.9% (n=22) were moderately dependent. After rehabilitation, the value of total dependents is 12.7% (n=8) and the presence of mild dependence and independents (15.9%; n=10 and 33.3%; n=21 respectively) appeared. Through the Wilcoxon test, it was confirmed that the percentage difference was significant (Z=-7.106; p=0.000), thus reiterating that the degree of independence effectively increased considerably after nursing rehabilitation, as shown in table 4 .

DISCUSSION

The average age of the users under study was 78 years old (78.41 ± 10.28 years old), corroborating other studies ^{, ,} .

With regard to gender, in our study, it was found that users were mostly female, in line with other studies that indicate that the person who receives care in the majority tends to be female ^{, ,} .

With regard to marital status, the vast majority of elements were married or widowed, data that are in line with studies by other authors who state that widowed and married situations were also the ones with the highest frequency of elderly people, although with some differences of percentage between them ^{, ,} .

The main cause of request for rehabilitation nursing intervention was the traumatic/orthopedic area, followed by the non-traumatic/medical area, the neurological area and finally the respiratory area, results contrary to other studies that show that the main cause of request was the neurological area ^{, ,} .

Regarding the main diagnosis, it can be stated that the request for rehabilitation nursing intervention was due, in most cases, to the diagnosis of femur fracture and subsequent placement of a total hip prosthesis, also highlighting the presence of Immobility Syndrome; the diagnosis of coxarthrosis and, with a lower incidence, the diagnosis of Gonarthrosis and Cerebral Vascular Accident (CVA). There are authors who argue that cerebrovascular diseases such as stroke are those that prevail in the clinical situation ^{, .}

In the initial assessment, most users admitted to the ECCI, referred for continuity of rehabilitation care, had high levels of severe dependence, corroborating studies ^{, , .}

With regard to activities of daily living, it is important to mention in relation to food that most of the sample was independent when referred for rehabilitation nursing care, 43 independent users for 20 dependents. Other studies have shown that in this activity of daily living, most users needed help ^{, .}

With regard to personal hygiene at the time of admission of users to the team, the percentage of independent users in this activity was 36.5%. After the intervention of the rehabilitation nurse, at the time of discharge, the number of independent users increased significantly, confirming what has been shown in other studies ^{, .}

With regard to ADL urinating more than half of the sample was continent. Of the remaining 20 who had some type of dependence, 8 were incontinent. Incontinence was found mainly in older age groups. These data contradict those found by other authors, in which the highest percentage of people studied were incontinent in the initial assessment and there was a statistically significant difference for the final assessment in the number of users who acquired continence ^{, ,} .

In defecating ADL, almost the entire sample was continent. Of the remaining 12 who had some type of dependence, 7 were incontinent. Other authors also found that the highest percentage of elderly people were independent for this activity of daily living, not needing help ^, . In this ADL, there was also no statistically significant difference in the evolution of independence from the moment of admission to the moment of discharge, however, other studies found that this difference existed ^{, , .}

In the global analysis of self-care, in our study, it was perceived that self-care defecating was the one in which there was a lower level of dependence. Other studies have shown that self-care was the personal arrangement that represented the lowest level of dependence ^{9), (10), (14).}

Comparing the two elimination activities of daily living, our study showed that dependence on urinary elimination is greater than dependence on fecal elimination. Against this result, other authors found that elderly people in general needed more care with regard to urinary incontinence in relation to fecal incontinence. ^{, , .}

Carrying out a comparative analysis regarding the moment of admission and discharge from the ECCI, in the ADL displacement, we can state that initially only 6 users were able to move independently, and the largest percentage was totally unable, in agreement with other studies ^{, ,} . However, at the time of discharge, 66.7% of users were already able to move around without any help and only 17.5% remained incapable, as also demonstrated by the study of other authors ^{, .}

In mobility, in an initial phase, most of the sample walked with help and 38.1% of users were completely immobilized, data that disagrees with another study that states that in the initial assessment, more than half of the sample was immobile . At the time of discharge, the appearance of independent elements was visible and it was found that the number of users completely immobilized decreased, which was also verified in another study .

With regard to the use of the toilet, it was found that only 22.2% of users were independent in this activity of daily living, data in agreement with those of other studies ^{, ,} . The evolution in this activity of daily living during hospitalization was quite expressive, and in the final assessment the percentage of independent users in this activity was 66.7%.

In the dressing/undressing activity of daily living in our sample, only 6.3% were independent. Taking into account the evolution during hospitalization, the percentage of totally dependent users decreased and 58.7% acquired independence in this task. Results similar to those observed in other studies ^{, , ,} .

Regarding care in the bath, only one user was independent. The remaining sample was dependent on this ADL, in line with data from other studies in which users needed full help with hygiene care ^{, ,} . After the rehabilitation nursing intervention, there was a positive evolution, with 42.9% of users already able to take a shower without any help.

The self-care where greater dependency was verified was clearly bathing, followed by dressing/undressing self-care, corroborating the findings of other authors ^{, , ,} .

Analyzing the ADL Going Up and Down Stairs, in our sample there were no independent users and incapable users represented 68.3%, data in agreement with what was observed in other studies ^, .

The results obtained showed a notable improvement in the functional independence of the users, throughout the period of hospitalization, which leads us to recognize the importance that rehabilitation programs have in promoting the functional independence of the user, as defended by another study, when stating that the rehabilitation nurse is one of the professionals who, not only because of the technical-scientific knowledge they possess, but also because of the longer stay close to the user, enables them to self-care, and promotes maximum independence .

Several studies have shown the existence of improvements in different activities of daily living, which means that the provision of Continuous Integrated Care had a positive impact on the functionality of users with regard to self-care ^{, ,} .

CONCLUSION

Continuous home care, provided by integrated continuous care teams, is increasingly important considering the current problem and emerges as a new health policy.

Taking into account the philosophy of continuous home care, the professional challenge is related to the inclusion of the user and integrated care provider in the clinical decision-making process. Only in this way, in a system of partnership, sharing and accountability, is it possible to achieve true effectiveness in the provision of care. The rehabilitation nurse has a fundamental role in the continuity of care insofar as he teaches, instructs and trains the skills of the user and informal care provider so that they are also the engines of the evolution of functionality in the continuity of care provided.

The present study intended to reflect on the problem of the evolution of functionality in the home context in beneficiary users of interventions in rehabilitation nursing. Thus, bearing in mind the objectives of the study, the main conclusion that we can assess was that the Wilcoxon test proved, with regard to functionality, that between the moment of admission (initial assessment) and the moment of discharge (final assessment) there was an evolution statistically significant in all activities of daily living except for elimination. From the results, it is possible to state that the levels of functional independence were clearly higher in the users studied, at the time of discharge, after the rehabilitation nursing intervention.

The rehabilitation nurse, as a case manager for users and an integral part of the health system, must commit to the philosophy of continuous care. We believe that the results obtained were an important contribution to improving the provision of rehabilitation nursing care at home.

The study presents the limitation of the sample, which boils down to only an integrated continuous care team, which reduces the range of the universe that could be covered. Despite the limitations inherent to a convenience sample, the study confirmed the importance of the rehabilitation nurse's role as a key element in the evolution of the user's functional independence at home.