Rehabilitation expertise
Last modified: June 6, 2025
How do you know that a professional is an expert? Because they have a healthcare professional qualification? And how does the organisation giving the qualification or employing them to deliver their professional skills know they have the skills? One answer is that the professional has been assessed against a raft of specific competencies, but is that sufficient? For example, a surgeon may be excellent at an operation. Still, they also need to know when to operate or, more importantly, when not to operate, and they must choose the most appropriate course of action.
However, there is an additional significant challenge in assessing a person’s rehabilitation expertise. Rehabilitation is not equivalent to therapy, nursing, psychology or medicine. Rehabilitation is complex, multi-professional, and based on a biopsychosocial model of illness, which is rarely taught in basic healthcare training. For the last 30 years, doctors have been required to demonstrate expertise in rehabilitation before becoming qualified experts in rehabilitation. No other profession has this option so far.
This page examines the challenges of defining rehabilitation expertise and evaluating professional expertise, with a focus on the rehabilitation context. It concludes that being competent in procedures is a necessary but not sufficient condition. A professional needs knowledge and skills in many other fields, most not easily measured, and so confirming professional expertise is a judgement based on evidence from observed behaviours rather than competency.
Table of Contents
Introduction
Would you let a doctor take full clinical responsibility for managing a clinical nursing service, for example, delivering nursing care in an acute admission ward for acutely ill patients? I doubt it, because few doctors possess the nursing expertise, a body of knowledge, and skills. They could not train or supervise nurses, they could not undertake many nursing procedures, and so on.
Yet many healthcare managers and clinicians believe that therapists, nurses, psychologists, and others can assume full clinical responsibility for a rehabilitation service. This overlooks the fact that doctors are required to undergo four years of training in rehabilitation after completing at least five years of postgraduate clinical medical training. Doctors must demonstrate expertise in rehabilitation, in addition to their professional medical knowledge.
The UK has an exceptionally low number of rehabilitation specialists compared to most European countries, making it currently unfeasible to provide rehabilitation expertise in every service. Other professions have not developed specific training in rehabilitation. Many people confuse rehabilitation with therapy or, less frequently, with nursing or psychology, but this is an error.
Any profession could easily use the principles underlying medical specialisation. This section of the site explores how, and this page introduces some of the key concepts.
Context – professionalism.
All healthcare workers are professionals. What features describe being a professional? In the commercial context, many lists of characteristics exist; for example, this site lists eight elements:
- Competence
- Knowledge
- Conscientiousness
- Integrity
- Respect
- Emotional intelligence
- Appropriateness
- Confidence.
Healthcare organisations have given much thought to professionalism. For example, the UK General Medical Council has published general guidance, Professional behaviour and fitness to practice.
It also covered professionalism in the first six paragraphs of the 2013-2024 edition of Good Medical Practice, where it highlighted:
- Good doctors make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity and within the law.
- Good doctors work in partnership with patients and respect their rights to privacy and dignity. They treat each patient as an individual. They do their best to make sure all patients receive good care and treatment that will support them to live as well as possible, whatever their illness or disability.
- You must use your judgement in applying the principles to the various situations you will face as a doctor, whether or not you hold a licence to practise, whatever field of medicine you work in, and whether or not you routinely see patients. You must be prepared to explain and justify your decisions and actions.
The Royal College of Physicians, in conjunction with the University of Oxford, published a report, Advancing Medical Professionalism in 2019, which used the definition from an earlier report in 2005: professionalism is “a set of values, behaviours and relationships that underpin the trust the public has in doctors.” The report’s main aim was “to help doctors reflect on and improve their professionalism in practical ways.”
The report presents professionalism as the assumption of various roles, or more precisely, a combination of seven distinct roles. While it specifically pertains to doctors, it could equally apply to any profession. The roles assumed by a doctor include the following:
- healer
- patient partner
- team worker
- manager and leader
- learner and teacher
- advocate
- innovator
In “A Blueprint to Assess Professionalism: Results of a Systematic Review” in 2009, Tim Wilkinson and colleagues found the following:
“Five clusters of professionalism were formed:
- adherence to ethical practice principles,
- effective interactions with patients and with people who are important to those patients,
- effective interactions with people working within the health system,
- reliability, and
- commitment to autonomous maintenance / improvement of competence in oneself, others, and systems.
Nine clusters of assessment tools were identified:
- observed clinical encounters,
- collated views of coworkers,
- records of incidents of unprofessionalism,
- critical incident reports,
- simulations,
- paper-based tests,
- patients’ opinions,
- global views of supervisor, and
- self-administered rating scales.”
The UK Health and Care Professions Council (HCPC) has produced Professionalism in Healthcare Professionals, which surveys how non-medical healthcare professionals interpret the concept of professionalism.
No unique agreed description emerged, and various approaches arose, including seeing it “as an holistic construct, as an expression of self, as a set of attitudes and behaviours, including appearance, and as a fluid, contextually defined concept.” Their summary conclusion was, “The data indicates that professionalism has a basis in individual characteristics and values, but is also largely defined by context.”
This overview of professionalism suggests that, although the concept of professionalism is ill-defined, it is not directly related to competencies. Thus, when considering how to establish that someone is an expert rehabilitation professional, one must consider much more than the clinical knowledge and skills a person has. As the HCPC report said, “The true skill of professionalism may be not so much in knowing what to do, but when to do it.”
Competencies, a dated approach to rehabilitation expertise.
Traditional medical training before 1948 was essentially an apprenticeship model based on knowledge about the human body and disease. Equipped with facts, the doctor learned through observing more senior doctors. In this way, they acquired further knowledge, many clinical skills and, unwittingly, a clear impression of how a doctor should behave. A similar approach was also adopted in most other healthcare professions.
As educational theory developed and the extent of harm an untrained doctor could cause increased, methods for confirming specific standards evolved. Postgraduate examinations of knowledge and skills emerged. The next step was to test skills directly, such as demonstrating that a doctor could safely perform a liver biopsy. These became competencies. The 2010 Rehabilitation Medicine curriculum included many competencies that trainees were expected to acquire.
Two problems arose. The number of competencies proliferated, making it increasingly difficult to demonstrate competency in all required tasks during the training period. It required considerable resources. Moreover, most were based on skills that needed to be practised regularly to be maintained. For example, during my training in neurology and neurosurgery, I developed proficiency in performing lumbar punctures. Two years later, working as a rehabilitation consultant, I would not have had much skill.
Second, the General Medical Council realised that almost all complaints against doctors were unrelated to specific clinical competence. In the introduction to their Generic Professional Capabilities Framework, the GMC wrote, “Our fitness to practise data shows that most concerns about doctors’ performance fall into one or more of the nine domains identified in this Generic professional capabilities framework.”
In other words, basing certification of expertise solely on achievement in competencies fails to identify a professional’s expertise because:
- the number of competencies identified exceeded the number that could realistically be acquired,
- the skill involved in many of the competencies would have been lost by the time the person completed the list,
- there was no assessment of a host of other skills and behaviours that characterise an expert professional.
Similar issues arise in all professional training.
Capabilities, a better approach to rehabilitation expertise.
The current solution adopted by many regulatory authorities is to use higher-level outcomes to validate expertise. Taking acute medicine as an example, rather than checking competency in the numerous procedural skills that may be required during a day on call, the validating authority asks whether the doctor can safely serve as the senior doctor responsible for all patients admitted over eight hours.
The UK General Medical Council has broken high-level outcomes into two groups. Six are generic abilities that apply to all doctors who practice independently, and between six and ten are specific to the speciality. In medical specialities, these outcomes are referred to as capabilities in practice. The general capabilities encompass matters such as communication, knowing how the NHS works, and familiarity with relevant legal and ethical guidance. The speciality capabilities focus on primary high-level functions that characterise the specialist.
This approach raises another problem: how does one assess capability? A fully trained doctor cannot shadow a trainee on an eight-hour acute-take session; it would be impractical and, in addition, would alter the situation because the trainee would know someone senior was available when making decisions.
The solution is to utilise the concept of entrustability; I discussed this in detail in a separate post. It essentially asks, “Would you trust this doctor to be responsible for this complex activity?” The answer is based on a wide range of documented reports on the trainee’s performance, including evidence of competence at some tasks.
This approach does not imply that competence in necessary tasks is unimportant. The trainee would only be trusted if they were competent. However, they only need to be skilled in functions relevant to their actual practice. An example from nursing will illustrate this.
I was once involved in discussions about the competencies required for nurses in neurological rehabilitation services. Three different experts were engaged across three services. Each service catered to various types of patients, necessitating different competencies for the nurses. For instance, one required skills related to older individuals following a stroke, another focused on younger patients after severe generalised traumatic brain injury with behavioural issues, and the third involved a care home with a mix of patients, including some on ventilators or with tracheostomies. The nurses could not have transitioned from one unit to another without acquiring new areas of knowledge and skills; nevertheless, all were experts in neurological rehabilitation nursing.
In other words, the competencies needed by any independent healthcare practitioner are determined by the specific post. Their expertise is judged at a higher, more general level. In a particular job, they may need to learn a range of specific competencies.
Gaining rehabilitation expertise.
An expert is someone who can safely manage a complex, novel situation. Even if the case is unique, they can draw on their existing knowledge and skills to make safe decisions and identify the additional support they require. Typically, they have encountered a situation similar to the one at hand before.
In rehabilitation, this translates into the following. During their training, the trainee should:
- see patients with a wide range of underlying conditions
- see patients of all ages
- work in a wide variety of different settings, including the community, care homes, acute wards, intensive care units, patient homes, inpatient and outpatient services etc
- see patients with problems covering a wide variety of complexity and severity
- manage patients over relatively prolonged periods
- become competent at the activities needed in the posts they hold
At the same time, they need to acquire more generic professional knowledge, skills, behaviours, attitudes, and values associated with being a rehabilitation professional, such as actively engaging in team activities.
This approach is an apprenticeship in a modern guise, incorporating formal educational principles such as regular structured assessments with constructive (formative) feedback. Like an apprenticeship, it involves inculcating professional behaviours and attitudes in a more structured and formal way.
Application across healthcare professions.
This post naturally draws on my experience of training doctors. Nevertheless, the principles of training should apply across all professions. The detailed training processes will differ; each profession will have its expected profession-specific areas of knowledge and skill (competencies). Nonetheless, the generic and professional capabilities, as well as the rehabilitation capabilities, will be similar.
The expected standards of performance may differ, and granular descriptors are required. Two existing methods are the four levels used in the Rehabilitation Medicine (see page 44) and other medical speciality curricula, and an extended ‘Miller’s Pyramid’ suggested by ten Cate and colleagues in “Entrustment decision making: extending Miller’s pyramid”
Granular grades of entrustability will be necessary to indicate various degrees of expertise. For example, a non-doctor who works in rehabilitation might possess basic training and be entrustable to act with direct or indirect supervision (Level 2 or 3 in the capability descriptors; Knows how or Shows how in the extended pyramid), whereas someone wishing to practise independently, potentially leading a service or working outside a service, would require Level 4 or Trusted.
Crucially, the standard of the top grade should be similar across all healthcare professionals, so that expertise in rehabilitation is equivalent across professions.
The suggested seven generic and seven rehabilitation specialist capabilities are described in pages within this section, shown in the table below.
Table showing links to all generic and rehabilitation capabilities
| Item/link | Title | Comment |
| Preface | Evolution of rehabilitation expertise | Traces the development of rehabilitation expertise and training and introduces high-level specialist attributes or training outcomes |
| GC0 | Generic professional capabilities | Overview of the seven professional capabilities all professionals who worki in healthcare need |
| GC1 | GC1: work with local organisations | Healthcare is one of the five major social agencies in all societies and patients will be involved with several so clinicians need to understand how they function. |
| GC2 | GC2: work within the patient's social context | A patient's social context has a crucial influence on rehabilitation and clinicians must be aware of it. |
| GC3 | GC3: communicate effeectively | Many parties have a stake in a patient's rehabilitation and the cliniciian must communiicate effectively with them all. |
| GC4 | GC4: quality improvement | Patients are enmeshed in a mixture of complex systems which will fail; each clinician must strive to monitor aand improve the systems. |
| GC5 | GC5: support research | Research is essential in rehabilitation, especially into clinical safety and eeffeectiveeness; all clinicians need sufficient expertise to assess research critically and help researchers. |
| GC6 | GC6: teaching and training | An essential element of being a professional is to educate others joining the profession; in rehabilitation this explicitly includes education people from other professions. |
| GC7 | GC7: maintain professional expertise | A rehabilitation expert must also maintain and develop their specific professional expertise. |
| RC0 | Rehabilitation capabilities | Overview of the seven capabilities that define an expert or specialist in rehabilitation, as an addition to their professional expertise. |
| RC1 | RC1: use the biopsychosocial model | Using the holistic biopsychosocial framework and model of illness is a defining feature of rehabilitation. |
| RC2 | RC2: rehabilitation planning | A rehabilitation expert should be able to make a provisional, initial plan when first seeing a patient and must participate actively in planning team activities. |
| RC3 | RC3: multi-professional teamwork | Multi-professional teamwork is another defining feature of rehabilitation and an expert must collaborate construcively with all team members. |
| RC4 | RC4: cross-boundary working. | Many non-healthcare aagencies will be involved with most rehabilitation patientss and an expert should be familiar and work collaboratively with other agency's teams. |
| RC5 | RC5: Complexity and uncertainty | Patient problems are complex and the many services they use form another complex system. An expert must manage the consequent uncertainty and negotiate legal and ethical issues too. |
| RC6 | RC6: support team approaches | To be effective, all team members need to use a consistent language, giive a consistent message, and use similar techniques. |
| RC7 | RC7: develop professional expertise. | An expert must maintain their particular profession expertise as well as their rehabilitation expertise; their role in the team is to offer their specific knowledge and skills. |
Conclusion
Rehabilitation is a specialised, team-based area of expertise that involves multiple professions. Each profession has its own certified expertise. At present, only doctors have additional certified knowledge in rehabilitation. It would enhance the effectiveness of the rehabilitation team and increase equity among its members if all professions could gain certified expertise in rehabilitation.
Expertise in rehabilitation requires trainees to develop a broad range of advanced skills, encompassing both generic professional and specialised knowledge and skills relevant to the rehabilitation process and its application to patients, regardless of their specific issues and locations. The competencies required by each profession will differ depending on the role and job requirements, and there are no universal competencies, even within a single profession.
The training required is best considered an apprenticeship, emphasising structured learning and feedback. The trainee needs to acquire specific knowledge and skills about rehabilitation, as well as a range of professional behaviours, values, and attitudes that characterise a professional.