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Rehabilitation Matters

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Rehabilitation expertise

How do you know that a professional is an expert? Because they have a qualification? And how does the organisation giving the qualification know they have expertise? 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, not to operate, and they must choose the most appropriate operation. This page considers the problems of defining rehabilitation expertise, and assessing professional expertise, relating the discussion to rehabilitation. 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

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:

  1. Competence
  2. Knowledge
  3. Conscientiousness
  4. Integrity
  5. Respect
  6. Emotional intelligence
  7. Appropriateness
  8. Confidence.

Healthcare organisation 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 covers professionalism in the first six paragraphs of Good Medical Practice, where it highlights:

  1. 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.
  2. 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.
  3. 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 has published a report, Advancing Medical Professionalism, 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 frames professionalism in terms of playing a role or, more accurately, a mixture of seven roles. It relates specifically to doctors but could apply to any profession. The roles played by a doctor are as a:

  1. healer
  2. patient partner
  3. team worker
  4. manager and leader
  5. learner and teacher
  6. advocate
  7. innovator

A systematic review by Tim Wilkinson and colleagues in 2009 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.”

While the concept of professionalism is ill-defined, it is unrelated 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. 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 applied to 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 particular skills directly, such as demonstrating that a doctor could biopsy a liver safely. These became competencies. The 2010 Rehabilitation Medicine curriculum had many competencies a trainee was supposed 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. Moreover, most were based on skills that needed to be carried out regularly if they were to be maintained. For example, during my training in neurology and neurosurgery, I became good at doing 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 failed in its goal of identifying professionals who were experts because:

  1. the number of competencies identified exceeded the number that could realistically be acquired
  2. the skill involved in many of the competencies would have been lost by the time the person completed the list
  3. there was no assessment of a host of other skills and behaviours that characterise a professional who is expert
new wave

Capabilities, a better approach to rehabilitation expertise.

The current solution adopted by many regulatory authorities is to use higher-level outcomes to determine qualification. Taking acute medicine as an example, rather than checking competency in the procedural competencies that may be needed during a day on-call, the authority asks whether the doctor can safely be the senior doctor responsible for all patients admitted over an eight-hour session.

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.

This approach throws up another problem, how does one assess the 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 use the concept of entrustability, discussed in detail in a post. It 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.

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 tasks relevant to their practice. An example from nursing will illustrate this.

I have been involved in discussions about the competencies needed for nurses in neurological rehabilitation services. Three different experts were engaged in three services. Each service took different types of patients. The nurses in each service needed other competencies. For example, one required skills related to older people after a stroke, one to younger people after severe generalised traumatic brain injury with behavioural problems, and one to a care home with a mix of patients, including some on ventilators or with tracheostomies. The nurses could not have moved from one unit to another without acquiring new areas of knowledge and skill, yet 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 expertise.

An expert is someone who can manage a complex novel situation safely. Even if the case is unique, they can use their existing knowledge and skills to make safe decisions and identify the additional support they need. Usually, they have seen a situation similar to the one facing them.

In rehabilitation, this translates into the following. During their training, the trainee should:

  1. see patients with a wide range of underlying conditions
  2. see patients of all ages
  3. 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
  4. see patients with problems covering a wide variety of complexity and severity
  5. manage patients over relatively prolonged periods
  6. become competent at the activities needed in the posts they hold

At the same time, they need to learn the more generic professional knowledge, skills, behaviours, attitudes, and values associated with being a rehabilitation professional such as engaging actively 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 includes inculcating professional behaviours and attitudes in a more structured, formal way.

Application across healthcare professions.

This discussion naturally draws on my experience of training doctors. However, rehabilitation is a team activity, and team members learn from each other. A rehabilitation doctor knows much more about speech and language therapy expertise and many other team members than any other doctor. Conversely, members of any team that includes a doctor will learn and, hopefully, be taught much about the medical aspects of the conditions being seen.

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 and the rehabilitation capabilities will be similar. The standards of performance will differ. Different or more granular grades of entrustability may be needed, indicating various degrees of expertise.

Conclusions

Rehabilitation is a specific team-based area of expertise with many professions involved. Each profession has certified expertise in their professional expertise. At present only doctors have additional certified knowledge in rehabilitation. It would improve rehabilitation team effectiveness and increase equity between members if all professions could gain certified expertise in rehabilitation.

Expertise in rehabilitation requires the trainee to acquire a range of high-level capabilities covering generic professional knowledge and skills and, in addition, knowledge and skill about the process of rehabilitation and their application to patients, whatever their problems and wherever they are. The competencies required by each professional will depend on the profession and the job demands, and there are no universal competencies even within a profession.

The training required is best considered an apprenticeship emphasising structured learning and feedback. The trainee needs to learn specific knowledge and skills about rehabilitation and a range of professional behaviours, values and attitudes that characterise being a professional.

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