Capability 6: support team treatments
An effective rehabilitation team will deliver a seamless package of interventions to a patient so that the patient feels that all team members are doing and saying the same. Consistency of approach is needed in all interactions, such as when explaining the formulation, considering prognosis, or delivering rehabilitation interventions. Consistency and repetition will magnify the effectiveness of each team member’s input (including nurses and doctors). The effectiveness of rehabilitation interventions should be “greater than the sum of their parts“, and it will be in a team where members have this capability. The capability can be seen as a whole in the Mind-Map below and downloadable from here. The complete list of rehabilitation capabilities is here.
Table of Contents
Thirty years ago, at Rivermead Rehabilitation Centre, we had a patient aged about 17 with severe hypoxic brain injury. Among her many problems, she had flexor spasticity in her right arm, causing contracture at the elbow. The physiotherapist used a plaster cast to control it. The patient had limited cognition and no insight and was not always cooperative with nursing care procedures. She found the right arm plaster cast was a good weapon, hurting several nurses. The therapist said the cast could not be removed. However, the service also had to manage: her eating disorder, her severe amnesia (no recall after five minutes), her lack of motor control, her double incontinence, and her general vulnerability. We resolved the dispute amicably, but the experience led to a much more team-based approach rather than a series of independent therapists, each doing their bit. It also precipitated our development of goal planning. (here and here) Following it, team members started to engage in more collaborative discussion and treatment. This capability is one long-term consequence.
Creating a rehabilitation environment
One way to define this capability is that it encourages and enables a ‘personal rehabilitation environment‘ to be created, whereby all the people involved with the patient support and reinforce those patient behaviours, increasing autonomy. There are two reasons for building a rehabilitation environment around the patient.
First, it is well established that direct face-to-face therapeutic contact rarely exceeds 10 hours a week, even in well-staffed inpatient rehabilitation units. There are 112 waking hours a week. This capability will increase the practice and feedback given in those 10 hours. It could and should also add additional training and feedback throughout the rest of the day. In inpatient settings, nursing and care staff will play a central role; families may also contribute. Family members and carers will be much more critical in other locations.
Second, it is also well established that a stimulating and challenging environment increases learning and recovery, provided the person can explore it. Part of this environment concerns objects that may facilitate or hinder the person from exploring the environment. However, the social environment has the more significant impact: do other people provide support and encouragement while also allowing the patient to face some risks, or do they suppress patient activity, perhaps because they wish to avoid trouble?
The social environment is complex. Most patients receiving multi-professional, team-based rehabilitation in the hospital will be in contact with between 10 and 20 individuals over a week. Most therapists are assisted by therapy assistants and often share responsibility for expert professional input; nurses (for in-patients) inevitably work in teams; doctors work as a group. In the community, the patients are still seen by many people from several or many different agencies and organisations.
What the patient needs is continuity and consistency of care. A Kings Fund research paper, ‘Continuity of care and the patient experience‘, has examined this problem in the context of people in the community. (here). Though the context differs from the hospital, much of the discussion and ideas are relevant.
The research paper makes an important conceptual distinction between two aspects of continuity of care. The first aspect is management continuity. This is better termed management consistency because it refers to everyone doing and saying the same thing, sharing an agreed understanding of the situation and having a uniform approach to its management. The paper adds that this includes information continuity, which refers to consistency in the information given by different parties.
The second aspect is relationship continuity – the same person or people seeing the patient over time. This is of great importance but is not part of this capability.
This capability addresses the matter of management consistency. The King’s Fund report suggests that general practitioners should and could lead on this in the community. However, the solution primarily focuses on case management – identifying organisations needed and getting them involved – and coordinating work through careful planning. There needs to be more discussion of how, in reality, any of the ideas proposed can be achieved. Furthermore, the report hardly considers the consistency of management for an individual patient.
Although outside the scope of this capability, the idea of relationship continuity is essential and possibly an even more powerful component of rehabilitation. It is tangentially related to capability five. In complex cases managed over time by the rehabilitation service, the team’s continued commitment to the patient (not necessarily one person) helps the patient the most. They do not need to go through the assessment, formulation, and planning processes repeatedly.
I initially imagined this capability applying to the constrained situation of an inpatient rehabilitation team. This capability applies to the rehabilitation team, including nurses and care staff, and might extend to family members and frequent visitors.
However, as I wrote this, I realised (a) that most rehabilitation should occur in the community and (b) that creating a rehabilitation environment was not only essential, but it was also achievable as part of this capability. The key is for an expert rehabilitation team to engage with the family, friends, and other closely involved people, teaching and training them to create and sustain ‘the rehabilitation environment’. The people involved might include carers paid for by social services, individual therapists working in the community who are not part of an expert team (but many will be), and others, as well as family and friends who visit regularly; this is discussed in a post on nursing homes (here) and one on the importance of social care in rehabilitation (here).
The capability has three components. First, an expert rehabilitation team should have or develop team policies for managing specific challenging problems and common problems. The professional needs to engage in the development and implementation of these policies. Second, In all their contacts with a patient, the professional needs to use and reinforce any treatments or approaches that can be used or supported safely. Third, the professional needs to teach both team members and others (e.g. family, community carers, and community rehabilitation staff) the techniques needed to continue patient learning skills.
In summary, this capability involves a mixture of learning basic approaches to a patient’s problems that lie outside the normal range of the issues managed by the professional and teaching both team members and other people living with or caring for the patient techniques they can use to maximise the patient’s learning and recovery. It involves enriching the patient’s environment so that more people become involved in training the patient as a natural part of day-to-day life, replacing an emphasis on ‘going to have treatment’ with a focus on ‘using the activity I need or wish to undertake as an opportunity to learn’.
The attitudes needed for this capability are:
- being collaborative,
- sharing professional knowledge and skills willingly
- taking a broad view of their role and a patient’s needs
- willingness to work directly with other professions,
The behaviours associated with this capability fall into two groups. The first group concerns establishing a team-based approach to patients, ensuring that the team will have a uniform, consistent system for patients. The second group concerns applying a uniform, consistent approach towards an individual patient.
A group of professionals may consider themselves a team. It may work collaboratively towards specific goals with selected individual patients. Yet, they may not have as a group an ethos of always sharing work, agreeing on an approach towards every patient, and agreeing on a common practice to problems commonly met.
From the patient’s perspective, the team must have some of a person’s characteristics. Specifically, the patient needs to learn that all team members will react and respond similarly to the patient’s request or behaviour. The patient and family will mistrust a capricious team just as they will mistrust a fickle person. Therefore, if necessary, the professional must initiate and participate in team discussions about achieving consistency.
Ensuring a common approach towards a single patient takes time and effort. It depends upon using common strategies across all patients for everyday problems so that the individual professional does not have to learn something different for each patient. When a patient has a specific, unique approach, the challenges are (a) to teach it to everyone who may come into contact with the patient and (b) to ensure that every person remembers and acts in the manner desired. Consistency can only be achieved partially. The greater the shared body of knowledge and skills within a team, the more likely consistency will be achieved.
There is one area where consistency is needed and can be increased: interactions between the patient and their family members, friends who visit regularly, and personal carers (usually at home). Consequently, training others to have a consistent facilitatory approach is essential to this capability.
The behaviours associated with developing a team culture of ensuring consistency across all interactions by all people are as follows. The professional:
- Initiates if needed and participates in team discussions on policies to ensure consistent management of common problems;
- Ensures that guidelines are developed for all common issues faced within the service;
- Suggests evidence-based approaches in the professional’s sphere of expertise;
- Ensures that policies within own area of professional expertise are following evidence and best practice guidelines;
- Checks that the policies of the team are consistent and compatible, one with another;
- Acts within the team policy recommendations when interacting with patients.
The behaviours associated with enacting a consistent approach to individual patients are:
- Advises the team on essential aspects to consider when agreeing on a system arising from own professional expertise;
- Follows the team’s coordinated approach to each patient seen;
- Explains the reasoning behind the approach to other team members (if needed), family and friends, and professionals involved from outside the team (e.g. home carers, community therapists);
- Where appropriate and safe, teaches family and friends, and professionals involved from outside the team how to approach the patient’s problems;
- Checks that approaches used with and policies applied to the patient are mutually compatible and consistent.
Knowledge and skills
The result of delivering a consistent care package over time, across settings, and between individuals can only succeed if the professional has a body of knowledge that enables them to be consistent. While this does not extend to acquiring the professional expertise of all other professions, it does extend to having sufficient knowledge about core matters that patients will ask about and common problems that may present to any team member.
For this capability, the professional will know the following:
- The main types of intervention generally used within rehabilitation: are exercise, practice, self-management and education, psychosocial interventions, and advising on care and support needs (see here);
- How to deliver each in outline, but especially how to teach self-management and to educate patients and families;
- The evidence behind the approaches used in team-based policies;
- The risks and the benefits associated with each of the procedures and recommended methods;
- The main facts (cause, specific treatments, prognosis) about the common diseases seen in patients seen by the team;
- How to support common specific treatments or approaches used within the group.
The skills needed relate to the person’s professional expertise and ability to use, adapt, and teach it in a team-centric approach to rehabilitation.
Therefore, a professional with this capability will be able to:
- explain the principles and the evidence behind own professional management techniques to team members;
- adapt and incorporate own professional expert management techniques (assessment, treatment, etc.) into team policies;
- adapt own professional techniques to teach them to other professions so that other team members can support the management needed;
- incorporate the management techniques of other professionals into their interactions with each patient;
- explain and justify their recommended management to other team members, the patient, family, and others involved.
In summary, this capability aims to increase the effectiveness of rehabilitation by adapting all interactions with the patient to facilitate learning, feedback and practice of all activities needing a change in as many situations as possible. This should involve team members (including nursing staff for inpatients) and all other people in regular, reasonably frequent contact with the patient – family, friends, carers, other rehabilitation teams or individuals. In this way, the patients no longer have intermittent and relatively little rehabilitation, restricted to times when undergoing face-to-face treatment, but are living within a rehabilitation environment which encourages and allows practice anywhere and at any time. The capability is shown just below.