D-0 Competencies for specialist capabilities
Three-quarters of the competencies needed to be an expert in rehabilitation are associated with specialist rehabilitation capabilities in practice. This is hardly surprising; indeed, it is interesting that the generic capabilities need so many competencies tailored to the requirements of rehabilitation experts. The competencies have been divided into two major groups: those associated with conditions or problems that can arise with most diseases and are not closely related to particular pathologies and those associated with organ-specific types of pathology. However, two competencies from the original medical syllabus covered matters that were traditionally the role of doctors, and they have been made into a third small group. I have adjusted them to emphasise their importance to all professions. They are concerned with the use of drugs (medications) and liaison with other services.
Table of Contents
Introduction - competencies and capabilities
Doctors have been responsible for prescribing drugs to patients since effective medications became available, and this was enshrined in law. In hospital practice, nurses were soon made accountable for giving prescribed medicines to patients and soon became responsible and could decide when to provide symptomatic drugs “as needed”. More recently, nurses, pharmacists, and other healthcare professionals can prescribe some medicines. Moreover, other healthcare professions may monitor the effects of drugs and, for many years, have suggested the use of drugs.
Doctors were also traditionally the leaders of healthcare teams; one role was making and receiving referrals. When most referrals were to other doctors, this was appropriate, but increasingly, teams deliver healthcare, and other professionals are often independent practitioners. It is no longer suitable for doctors to be the only or assumed professionals for referrals to or liaisons with other services needed by patients.
Therefore, all healthcare professionals who acquire expert rehabilitation specialist capabilities in practice demonstrate competence in the two activities in this group. This is important now and will become vital as the service delivery unit becomes multiprofessional teams rather than individual professionals.
This diffusion of expertise into teams should increase efficiency, effectiveness, and safety as all become less dependent on the quality of specific individuals. For example, surgical practice has demonstrated this in the World Health Organisation’s preoperative surgical safety checklist, a multi-professional activity.
Pharmacological agents, drugs are potent treatments for many diseases and may lessen many troublesome impairments such as spasticity or patient experiences such as pain. At the same time, they may account for many iatrogenic problems, some due to frank errors but primarily due to a lack of attention.
In rehabilitation, as in most areas of healthcare, doctors, the primary prescribers of drugs, only see the patient intermittently. The patient is mostly in contact with the team; this is especially true for hospital inpatients but is also true in the community and care homes. Patients will report their problems to members of the team first.
Thus, the team is essential in monitoring medication’s intended and unintended adverse effects.
Furthermore, team members may notice potential areas for improving medication use. For example, they may learn about a problem that a drug might help with and be able to suggest the medicine to the doctor. Equally, a team might notice duplication of drugs, two being given where one would suffice.
One particular concern is to minimise the adverse effects of drugs. Most patients have long-term and frequently multiple conditions, see several doctors, and take medicines for years. A rehabilitation team with a holistic approach should review medication and deprescribe wherever possible. Having more team members with expertise in the use of drugs could reduce the rate of unnecessary medication.
All these benefits depend upon all rehabilitation team members knowing about medications used in their patient population. This competency addresses this need as a part of acquiring rehabilitation specialist capabilities.
Within a single healthcare organisation, the patient will be cared for by a rehabilitation team rather than a specific individual or a single profession. However, teams do not work in isolation, and most rehabilitation patients are seen by several other groups of professionals, and not only within healthcare. This is illustrated in this figure.
Most patients referred to a rehabilitation service are already in contact with some services. However, many will need assistance from other services. As I have often pointed out, there is no coherent framework for rehabilitation services; it is genuinely chaotic. This makes it impossible for a patient to negotiate the patchwork of services and is challenging for the rehabilitation team.
As with ensuring the safe and appropriate use of drugs, a team will be much better than an individual at acquiring and maintaining a bank of information about other services that might benefit your patient. It is also better if the referral is made by the team member most able to provide the necessary information and most acceptable to the other service.
Therefore, this competency is also essential for rehabilitation specialist capabilities.
This introductory page for this section has highlighted the considerable benefits of sharing competencies across as many team members as possible. It reduces dependence upon a particular person or profession. Having more people in the team able to collect information and having sufficient understanding to evaluate all aspects of the situation reduces risks of missing opportunities to prevent harm and increases efficiency and effectiveness. By ensuring that all team members have competency across various activities, often outside their specific professional expertise, we can capitalise on the power of teamwork.