A patient’s rehabilitation curriculum?
A patient’s father recently asked me, “What is the usual rehabilitation curriculum for someone with problems like my son’s?”. Until then, I had only considered a rehabilitation curriculum in the context of educating and training healthcare professionals about rehabilitation. I had never thought of a patient’s rehabilitation curriculum. Although I have often said rehabilitation is an educational activity, I had never made the obvious leap to having a curriculum for the patient and family. The recent academic focus on relatively few higher-level outcomes from medical training, called Capabilities in Practice, instead of concentrating on multiple specific competencies, translates well into goal setting and rehabilitation planning. At first glance, the word curriculum seems inappropriate. Still, I will suggest in this post that it could demystify some of the planning processes and help people understand rehabilitation’s adaptive and educational nature. It may also suggest ways to increase the efficiency and effectiveness of rehabilitation.
Table of Contents
Why have a patient's rehabilitation curriculum?
I have explained the process of rehabilitation in some detail on this site. To summarise, a patient starts with difficulties in achieving their goals, and the rehabilitation team collects data to analyse the situation, ending with an explanatory formulation. The rehabilitation team’s expertise enables it to foresee, to an extent, what changes are possible and how they might occur, and they discuss this prognosis with the patient to find goals and actions that fulfil their goals and are compatible with their values. They then construct a plan and either act or ask others to act. Last, they review progress. This process may continue over weeks, months, or years depending upon the complexity and severity of the problems.
The actions almost all involve learning and adaptation. The patient or their carers may need to relearn how to perform a previously achieved activity, often in a different way; they may have to learn how to use equipment not previously used, some being quite complex; they may need to change their long-term aims and learn new skills to achieve new goals; and they may need to learn how to manage inevitable disappointment, distress, and other sequelae of their illness.
A child starting school also needs to acquire a vast range of knowledge and skill vital to become an adult able to function fully as a member of society. The educational system mistakenly equates education with competencies in specific skills, probably in response to government pressure. Even so, the child in school will acquire many vital life skills, such as working with others collaboratively, developing and maintaining friendships, handling challenging social situations etc.
Later in education, the adolescent or adult learns more, usually with a long-term goal in mind, either in terms of work or achieving an academic purpose, such as understanding the historical antecedents of the Great War.
The similarities are obvious. Still, exploring the differences may give further insights and ideas. For example, the content and goals of rehabilitation are encapsulated within a rehabilitation plan, but in education, the content and goals are in a curriculum.
Outcomes
Education and rehabilitation both have long-term high-level goals related to social role functioning and satisfaction with life. Pre-existing roles usually influence the person’s goals in rehabilitation after an illness starting in adulthood. In contrast, expectations and social goals may be less precise in education and when a child or adolescent rehabilitates. Long-term high-level goals are a significant determinant of motivation, engagement, and success because a person without such goals will often not participate.
This is obvious in education. Because the government emphasises specific knowledge, usually academic and not practical knowledge, children and adolescents see little reason to participate. Engagement would be better if education were framed as education for life, including a work career and enjoyable leisure activities that would be assessed when someone had been out of education for ten years; I am not suggesting this would be a realistic option! Some universities do focus on employment rather than qualifications when advertising their courses.
Unfortunately, rehabilitation services tend to focus on activities, not least because these are more easily measured and are required by funders. Unless the rehabilitation team also sets distant social goals and highlights how the work on activities will help, the patient’s participation may be limited.
Post-graduate, professional educational curricula, such as the Rehabilitation Medicine curriculum, now use high-level outcomes to guide content and move away from specific competencies.
Education and rehabilitation also both use middle-term outcomes. In rehabilitation, they are specific activities such as dressing without help, cooking a meal safely and successfully, or conversing with a stranger. The effects may be assessed using goal attainment scaling or standardised measures. In education, they are usually examinations to be passed. These examinations assess knowledge or skills.
In professional training, progress is assessed in meetings with a trainer or using formative (i.e., developmental) performance assessments. In education, progress is evaluated by the teacher on classwork.
In both spheres, the content is given in a syllabus, such as the Rehabilitation Medicine syllabus, which, in education, is often very proscribed. In rehabilitation training, it is only guidance and is not compulsory.
Actions
The actions taken by professionals with patients or pupils are also similar. The therapist or teacher will identify a skill or piece of knowledge for the person to learn and start teaching it.
There is one significant difference. Much rehabilitation therapy is given 1:1, whereas most teaching in education is on a group basis, with numbers varying between 1:4 rarely to 1:30 or more.
The actions combine didactic teaching, giving specific knowledge for learning, practising a skill, and guided self-learning coupled with assessment and feedback.
Education places much greater emphasis on homework and other self-guided learning than rehabilitation has. It has also included peer-supported learning, with pupils teaching each other – this may not be formally timetabled, but it happens all the time and helps both the teaching and the learning pupil.
Insights from comparison.
What can rehabilitation learn from this? And what might education learn?
The similarities are easily seen. They support. the hypothesis that rehabilitation can be considered an educational process. Comparing the two activities is valid; any insights could be transferred or shared.
Both rehabilitation and education up to the age of 17 often prioritise the concrete, short-term outcome over longer-term goals, to the person’s detriment and, ultimately, lead to less participation by the person and less effective learning. In university and postgraduate education, there is greater recognition of higher-level outcomes and more engagement.
Could we learn from post-graduate training, adapting the idea of entrustable capabilities? In rehabilitation, the concept of being entrusted builds in recognition of risk and uncertainty and might counter the risk-averse nature of professionals and organisations. This would particularly help discharge, often delayed by fears that the person will not manage.
It would be more challenging in education because entrustability is a judgement based on evidence and a good understanding of the person in a particular context.
Next, it is striking that rehabilitation rarely uses group sessions, whereas education rarely uses 1:1 sessions. Indeed, 1:1 educational sessions are the equivalent of an educational supervision meeting between a trainer and trainee. Rehabilitation is beginning to use peer support as a formal part of the rehabilitation process. There is undoubtedly much informal and helpful patient-patient and carer-carer interaction associated with sessions.
There is significant scope for change in the way rehabilitation interventions are delivered. We should consider how we can use groups more. It is more difficult in rehabilitation because the numbers are small, and patients do not arrive in a cohort, unlike pupils in education. Currently, groups tend to be planned, but in any service, opportunities to form a group are likely to arise, and ad hoc groups should be expected and facilitated.
In the same way, planning peer support is constrained by small numbers and the need for predictable cohorts, although some trials have been undertaken. However, it is predictable that opportunities will arise by chance, and the service should facilitate peer support when the opportunity arises. An attractive social meeting place would likely increase peer and carer support groups.
Educational settings expect pupils to work without a teacher present and to learn the skill of learning without a teacher, relying on other pupils and their self-education and problem-solving skills. Rehabilitation already teaches self-management – sometimes. We probably fail to set learning goals, a goal of becoming able to problem-solve and learn independently. This is a skill that most professionals must learn; we should formally teach patients the skill.
Educational settings also provide an environment where pupils can continue learning when not in lessons, such as libraries, language laboratories, or science laboratories. From a relatively young age, self-directed learning is expected. People receiving rehabilitation in hospitals or other residential placements can often not use training facilities outside planned therapy sessions. They are rarely encouraged to practice independently. Patients at home are more likely to be given some homework.
Next, as I have already implied, rehabilitation and education increasingly concentrate on specific, measurable competencies or activities without considering whether they are valuable to the person.
Finally, education is continued throughout a person’s life. This may be to develop work expertise, either because the nature of work changes or because new methods evolve. It may be to respond to changes in life, such as moving to a country with a different language or retirement. Professionals are expected to continue learning and are monitored.
The same should apply to rehabilitation. Patients should be able to access expert rehabilitation when needed, a standard supported by the Community Rehabilitation Alliance; “I can refer myself by contacting the service directly.”
A rehabilitation plan – or curriculum?
Should we follow my patient’s father’s idea and refer to the rehabilitation curriculum for our patient?
The rehabilitation plan currently has many names, as I have discussed. I suspect that the range of purposes subsumed within the phrase, rehabilitation plan, is too great for any other term to be used. On the other hand, the term curriculum could apply to most plans. What are the advantages and disadvantages?
One disadvantage would be adding another term, potentially increasing confusion and misunderstanding. Moreover, some professionals, patients, and families might be confused because rehabilitation would use a word from education. Third, one must distinguish a patient’s rehabilitation curriculum from the training rehabilitation curriculum. In practice, the risk of confusion is small.
There are several advantages. The term is not part of the rehabilitation jargon; therefore, its meaning will likely be evident. In contrast, some commonly used words, such as review meeting, care planning, or goal planning, are unclear to most people outside rehabilitation. Indeed, its close association with education further highlights the crucial role of learning and teaching within rehabilitation.
Suppose the term, curriculum, were to be introduced. In that case, it might catalyse other changes derived from education, such as more emphasis on homework (rather than practising on your own), learning from other patients, and learning how to rehabilitate yourself.
Therefore, the term curriculum used to describe the plan for a patient is certainly not inappropriate or harmful, and introducing it and explaining it to patients and families might encourage a more productive approach to rehabilitation.
Conclusion
I have shown that rehabilitation is simply an educational process for people with longer-standing illness-related problems. The similarities between rehabilitation and education dwarf the differences. The comparison highlights opportunities for rehabilitation to alter its practice, for example, undertaking more group work with patients and altering the environment so that peer support is facilitated and encouraged and patients can practice outside therapy sessions. Introducing the term in place of a rehabilitation plan or other terms might also encourage a reconsideration of current practice and might increase awareness of the central role of education and learning in rehabilitation.