Rehabilitation Nursing: A transformative perspective focused on the person, family, and community

Authors

DOI:

https://doi.org/10.56294/nds2025420

Keywords:

Rehabilitation Nursing, Nursing Theory, Patient-Centered Care

Abstract

Introduction: Rehabilitation Nursing requires a distinct and evolving body of knowledge that strengthens its scientific and professional identity. The practice of Rehabilitation Nurse Specialists must be grounded in theoretical frameworks that support critical, reflective, and individualized care, ensuring quality and intentionality in interventions. 
Objective: This theoretical-reflective article aims to analyze the intervention of Rehabilitation Nursing in the community, focusing on fundamental, person- and family-centered care that promotes adaptation to lived experiences.
Development: The analysis is structured around three complementary theoretical references: the Fundamentals of Care Framework, the Person-Centred Nursing Framework, and the Roy Adaptation Model. The interrelation of these frameworks allows rehabilitation nurse specialists to adjust care continuously to contextual, personal, and organizational changes, fostering evidence-based, integrated, and individualized community care.
The home environment is a privileged setting for person-centered Rehabilitation Nursing that enhances autonomy and well-being. Given the complexity of care and population aging, it is essential for Rehabilitation Nurse Specialists to critically reflect on their practice, anchoring interventions in theoretical frameworks to ensure differentiated, humanized, and high-quality care. This perspective reinforces the ontological identity of nursing, rooted in person and family centred care. 
Conclusions: Therefore, advancing Rehabilitation Nursing based on theoretical frameworks that correspond, in a comprehensive and individualized manner, to the real human responses of the population, contributing to improve quality of life, promote functional rehabilitation and independence among people receiving care.

References

1. Sun X, Li X. Editorial: Aging and chronic disease: public health challenge and education reform. Front Public Health. 2023 May 9; 11:1175898. https://doi.org/10.3389/fpubh.2023.1175898

2. World Health Organization. Ageing and health. Geneva: WHO; 2022. https://www.who.int/news-room/fact-sheets/detail/ageing-and-health

3. Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019. Lancet. 2021 Dec 19;396(10267):2006–17. https://doi.org/10.1016/S0140-6736(20)32340-0

4. World Health Organization. Rehabilitation 2030: a call for action. Geneva: WHO; 2017. https://www.who.int/initiatives/rehabilitation-2030

5. Andelic N, Moksnes H, Rasmussen M, Schäfer C, Hellstrøm T, Howe E, Sveen U, Perrin P, Røe C, Anke A, Soberg H. Needs for Community-Based Rehabilitation Services and Support 12 Months After Moderate and Severe Physical Traumatic Injuries. Am J Phys Med Rehabil. 2024;103(8):740-744. https://doi.org/10.1097/phm.0000000000002492

6. Ordem dos Enfermeiros. Regulamento dos Padrões de Qualidade dos Cuidados Especializados em Enfermagem de Reabilitação. 2018 Jan 26. https://www.ordemenfermeiros.pt/media/5682/ponto-4_regulamento-dos-padr%C3%B5es-qualidade-ceer.pdf

7. Ribeiro O, Moura M, Ventura J. Referenciais teóricos orientadores do exercício profissional dos enfermeiros especialistas em enfermagem de reabilitação. In: Enfermagem de Reabilitação- Conceções e Práticas. 1st ed. Lisboa: Lidel; 2021. 48–55.

8. Registered Nurses’ Association of Ontario [RNAO]. Transitions in care and services. 2nd ed. Toronto (ON): RNAO; 2023.

9. Resolução da Assembleia da República n.º 392/2019, May 3. Diário da República, Série II (85). https://diariodarepublica.pt/dr/detalhe/regulamento/392-2019-122216893.

10. Kitson AL. The fundamentals of care framework as a point-of-care nursing theory. Nurs Res. 2018 Mar; 67(2): 99–107. https://doi.org/10.1097/NNR.0000000000000271

11. McCance T, McCormack B. The Person-centred Nursing Framework: a mid-range theory for nursing practice. J Res Nurs. 2025 Feb;30(1):47–60. https://doi.org/10.1177/17449871241281428

12. Tomey A, Alligood M. Teóricas de enfermagem e a sua obra- modelos e teorias de enfermagem (5ª edição). Lusociência; 2004.

13. Vieira M, Martins M, Martins R, Fernandes C. Traçado da intervenção do Enfermeiro de Reabilitação – organização de cuidados para um envelhecimento saudável e ativo. Rev Port Enf Reab. 2023 Jun 19; 6(1): e316. https://doi.org/10.33194/rper.2023.316

14. Faria A, Martins M, Ribeiro O, Ventura-Silva J, Fonseca E, Ferreira L, Laredo-Aguilera J. Effect of the Active Aging-in-Place–Rehabilitation Nursing Program: A Randomized Controlled Trial. Healthcare. 2023 Jan 16; 11 (2): 276. https://doi.org/10.3390/healthcare11020276

15. Sousa L, Martins M, Novo A. A enfermagem de reabilitação no empoderamento e capacitação da pessoa em processos de transição saúde e doença. Rev Port Enf Reab. 2020 Ago 8; 3(1):64-69. https://doi.org/10.33194/rper.2020.v3.n1.8.5763

16. Dragosits A, Martinsen B, Hemingway A, Annelise Norlyk. Coming home: older patients’ and their relatives’ experiences of well-being in the transition from hospital to home after early discharge. Int J Qual Stud Health Well-being. 2024 Jan 3;19(1). https://doi.org/10.1080/17482631.2023.2300154.

17. Hjelle K, Tuntland H, FØrland O, Alvsvåg H. Driving forces for home-based reablement; a qualitative study of older adults’ experiences. Health Soc Care Community. 2017 Sep; 25(5): 1581-1589. https://doi.org/10.1111%2Fhsc.12324

18. Oliveira C, Couto G, Silva R. Enfermagem de reabilitação nos cuidados de saúde primários. In: Enfermagem de Reabilitação - Conceções e Práticas. 1st ed. Lisboa: Lidel; 2021. 654–70.

19. Kitson A, Conroy T, Kuluski K, Locock L, Lyons R. Reclaiming and redefining the Fundamentals of Care: Nursing’s response to meeting patients’ basic human needs. Adelaide, SA: University of Adelaide; 2013.

20. Sun W, Ashtarieh B, Zou P. The safety challenges of therapeutic self-care and informal caregiving in home care: A qualitative descriptive study. Arch Gerontol Geriatr. 2021; 94:104344. https://doi.org/10.1016/j.gerinurse.2020.07.013

21. Mattos MK, Gibson JS, Wilson D, Jepson L, Ahn S. Shared decision-making in persons living with dementia: A scoping review. Dementia. 2023;22(2):450–68. https://doi.org/10.1177/14713012231156976

22. Chen L. Effectiveness of the Roy adaptation model-based nursing intervention in improving physiological, psychological, and social outcomes in patients with Parkinson's disease. BMC Neurol. 2025; 25:232. https://doi.org/10.1186/s12883-025-04232-2

23. Morris JH, Kayes N, McCormack B. Person-centred rehabilitation–theory, practice, and research. Front Rehabil Sci. 2022 Jul 20; 3:980314. https://doi.org/10.3389/fresc.2022.980314.

24. Registered Nurses’ Association of Ontario [RNAO]. Person- and Family-Centred Care. Toronto (ON): RNAO; 2015 May.

25. Kang E, Kim MY, Lipsey KL, Foster ER. Person-centered goal setting: a systematic review of intervention components and level of active engagement in rehabilitation goal-setting interventions. Arch Phys Med Rehabil. 2022 Jan;103(1):121-130.e3. https://doi.org/10.1016/j.apmr.2021.06.025.

26. White, J., Gunn, M., Chiarella, M., Catton, H., & Stewart, D. Renewing the Definitions of 'nursing' and 'a nurse'. International Council of Nurses [Internet]. 2025 Jun. ICN_Definition-Nursing_Report https://www.icn.ch/sites/default/files/2025-06/ICN_Definition-Nursing_Report_EN_Web_0.pdf _EN_Web_0.pdf

27. Yun D, Choi J. Person-centered rehabilitation care and outcomes: a systematic literature review. Int J Nurs Stud. 2019 May; 93:74-83. https://doi,org/10.1016/j.ijnurstu.2019.02.012.

28. Jesus TS, Papadimitriou C, Bright FA, Kayes NM, Pinho CS, Cott CA. Person-centered rehabilitation model: framing the concept and practice of person-centered adult physical rehabilitation based on a scoping review and thematic analysis of the literature. Arch Phys Med Rehabil. 2022 Jan;103(1):106-120. https://doi.org/10.1016/j.apmr.2021.05.005.

29. Grover S, Fitzpatrick A, Azim FT, Ariza-Vega P, Bellwood P, Burns J, Burton E, Fleig L, Clemson L, Hoppmann CA, Madden KM. Defining and implementing patient-centered care: An umbrella review. Patient Educ Couns. 2022 Jul;105(7):1679-1688. https://doi.org/10.1016/j.pec.2021.11.004.

Downloads

Published

2025-09-30

How to Cite

1.
Novo B, Guerra N, Sousa L, Severino S. Rehabilitation Nursing: A transformative perspective focused on the person, family, and community. Nursing Depths Series [Internet]. 2025 Sep. 30 [cited 2025 Oct. 6];4:420. Available from: https://nds.ageditor.ar/index.php/nds/article/view/420