Rehabilitation capabilities

Rehabilitation capabilities are the high-level characteristics that demonstrate that a healthcare professional has expertise in rehabilitation, in addition to their professional expertise. Formal, official recognition that clinicians could have specialist expertise in addition to their general professional first occurred in the UK in 1997, when the General Medical Council specifically recognised medical specialities. Every doctor in a secondary care specialty is supposed to acquire a set of specialist Capabilities in Practice (sometimes given other names), as well as a generic set, which is the same in every specialty. The UK 2021 curriculum for doctors training in Rehabilitation Medicine has set out eight specialist professional high-level outcomes (Capabilities in Practice) for the training programme. This part of the site explores how these can be adapted to all professions involved in rehabilitation. These capabilities are complemented by seven generic capabilities. (here)

Context of rehabilitation capabilities

The eight specialist rehabilitation Capabilities in Practice acquired by doctors who achieve specialist medical certification in Rehabilitation Medicine define what particular expertise (knowledge and skills) a doctor practicing rehabilitation has in contrast to other doctors. A cardiologist, for example, will have a different set of specialist Capabilities in Practice focused on the particular knowledge and skills needed to be a cardiologist. The specialist capabilities, in effect, define the speciality.

However, with the exception of a set of competencies put forward by nurses in the United States (not a nationally or even a State recognised set), there are no other professions that specifically train in rehabilitation. To a greater or lesser extent, other professions will learn about some aspects of rehabilitation before qualifying. And, to a certain extent, some people in other professions may learn about certain aspects of rehabilitation or gain an MSc.

There is no nationally recognised clinical qualification to show that other professions have training in rehabilitation itself.

This seems unfair. More importantly, it has an adverse effect on multi-disciplinary teamwork. Different team members have differing understandings of: what rehabilitation is; what problems are or are not within the scope of rehabilitation; what outcomes are or are not within the scope of rehabilitation; and so on. For example, phrases such as “suitable for rehabilitation” or “ready for rehabilitation” are commonly used, and they suggest that some people have a limited view of the nature of rehabilitation and the responsibility of rehabilitation teams. Moreover, there is often an implicit assumption that rehabilitation is synonymous with therapy, a mistaken assumption. If all people involved in rehabilitation received training in rehabilitation in addition to their professional training, teams would probably be much more effective and unified

Rehabilitation capabilities

The remainder of the page discusses further development of the proposed seven specialist capabilities in practice for anyone wishing to acquire expertise in rehabilitation. They will be generic, not specific to any profession. They are derived from work I have been involved in: writing the curriculum and syllabus for doctors training in rehabilitation, and writing about capabilities and competencies. As anyone who has read or reads earlier work, there are some small changes but the general thrust remains the same. This page sets out my current (March 2021) ideas about rehabilitation capabilities. I am interested in any feedback.

Addition to professional expertise

These capabilities must be seen in context. They apply to people who have acquired a professional qualification in some aspect of clinical healthcare. My assumption is that this will usually be at a degree level, but I do not think that it is essential and this could be debated.

The specialist capabilities are predicated on the person also keeping their professional skills up-to-date, and complying with any regulations concerning continuing professional development, ongoing training, maintaining registration etc.

The specialist capabilities also assume that the person has generic capabilities which concern working with patients within a healthcare system. These abilities are sometimes referred to as Generic Professional Capabilities, for example by the General Medical Council (here). In medical curricula they are referred to as Generic Capabilities in Practice. They cover matters such as maintaining professional standards and behaviours, communication skills, knowledge of the NHS etc.

Seven generic capabilities that are relevant to rehabilitation are illustrated here.

The seven capabilities

The seven capabilities to be outlined in this page are shown in a Mind-Map here, and each will be discussed in more detail in other pages (yet to be written [28th March 2021])

Biopsychosocial model

The first capability concerns embedding the biopsychosocial theory of illness into all areas of practice – clinical, research, and service design and management. The extent to which a person uses it in each of these spheres will depend upon the nature of their job. The capability is concerned about the extent to which it is thoroughly embedded into a person’s thinking, and used in almost every relevant situation.

The Capability in Practice is:

“Able to use the biopsychosocial model of illness as a structure and framework for all rehabilitationrelated clinical, academic, and management activities.

Rehabilitation planning

The first capability will include within its ambit the formulation of a patient’s situation, which is the immediate precursor to planning what to do. This forms the next major capability. A patient referred to a rehabilitation service may, and usually is seen by a single member of the team. That person should not only be capable of developing an initial formulation (which will obviously be refined later when other team members see the patient), but should be capable of developing an initial outline plan. This allows a more efficient response by the team as a whole and gives the patient some insight into what to expect.

The Capability in Practice is:

“Able to develop a rehabilitation plan for a patient, both when the professional is the first to see a patient and when in a team planning meeting, and ensuring that the plan covers all aspects of a patient’s need both from the team and from other services and agencies.”

Be a team-worker

Teamwork is central to rehabilitation, as it is in much of healthcare. However, education and training to improve teamwork seem rare. Team ‘away days’, supposed to improve teamwork, are not educational and, in my limited experience, have little effect. Complex problems, of any sort, are best resolved through effective teamwork and rehabilitation problems are complex. Being a team member requires everyone to be able and willing to lead when needed, and equally willing to be led.

The Capability in Practice is:

“Able to work as a full and equal member of any multi-professional team, participating actively, sharing responsibilities and blurring professional and role boundaries.”

Work across all boundaries

Many if not most patients being seen in a rehabilitation service will also have contact with other services and agencies: home care teams, Social Services; housing department, one or two other hospital services, primary care – the list is endless. This drawing illustrates the situation. (here). Consequently rehabilitation professionals also have to be expert at working across almost all boundaries – as illustrated here.

The Capability in Practice is:

“Able to work across all organisational, geographic and time-based boundaries, collaborating actively with other professionals, teams, and organisations.”

Managing uncertainty

One major implication of the biopsychosocial model of illness is that situations are complex, with multiple interacting factors influencing a patents abilities, symptoms and other problems, with many non-linear relationships. The uncertainties generated by this complexity adds to the non-trivial uncertainties associated with disease pathology, treatment, and prognosis to make uncertainty the normal state of affairs. Nothing can be predicted with absolute certainty. The surprise is how well we can predict. Yet patients, managers, families, and funders all want a level of certainty that cannot be offered. And many professionals, during their training, develop an expectation of certainty: “For a patient with condition X, treatment Y will lead to great improvement.” The rehabilitation expert recognises and manages the uncertainty.

The Capability in Practice is:

“Able to recognise, accept, explain and manage the uncertainty present in all aspects of rehabilitation, helping all people involved to understand and work with the patient despite the uncertainty.”

Support team approach

One characteristic of a team is the blurring of boundaries between the professional roles, and the sharing of responsibilities for work undertaken by the team. As implied earlier, a single team member should be able to know, in outline, what help and input each other member might offer a patient. One particular feature is in supporting the actions of other team members. The obvious examples include reacting to unwanted behaviour by a patient in the team’s agreed manner, usually advised on by a clinical psychologist, and communicating with a patient who has a communication problem in an agreed manner. Giving a common message on prognosis, or a common explanation of treatment are other examples.

The Capability in Practice is:

“Able to support and use the team’s approaches and policies towards patient management, both in general across all patients and in specific situations with specific patients.”

Use professional expertise

Each team member has a body of professional expertise, knowledge, and skills they have that is specific to their profession. Some of this will be in common with other professions, but some of it will be unique to the profession. It is obviously expected that every team member will maintain and increase their professional expertise and use it for their patients. At the same time, they will be expected to explain and teach about their specific unique expertise. This will facilitate appropriate requests from other team members, will give other team members appropriate expectations of what might be achieved by the profession, and will help them understand and interpret any advice given or conclusions drawn.

The Capability in Practice is:

“Able to use their specific professional expertise to assess and treat individual patients, to teach other team professions about the strengths and limits of their professional expertise, and to help develop team protocols and procedures.”

Demonstrating capability

The capabilities, as stated, are difficult to interpret. How would the person know what they had to do or to learn? How would another person judge that someone had the capability?

The General Medical Council curricula for doctors require a set of indicative behaviours (by the doctor) to be provided, and this seems a useful and usable method for describing the capability. They are indicative in that they are not intended to be comprehensive or a definitive set of criteria. On the other hand, they are a useful way to illustrate the range and types of ways that the capability will influence practice.

One criticism of the capability framework is that it gives no guidance on specific learning. In the rehabilitation medical training programme, this gap has been covered, partially at least, by setting out a syllabus. The medical syllabus covers many areas that are or could be considered specific professional matters. The syllabus covers a wide range also because doctors in training may be faced by any of a very wide range of possible patients, whereas any team will have a much more restricted range of patients.

Each capability will be discussed on a separate page and, as a compromise, the discussion will also touch on the knowledge and skills needed to support the capability.

Measuring capability

The medical curricula use the concept of ‘entrustability’ to determine whether (or not) a trainee is sufficiently trained to be offered a certificate that they are fully trained. This concept, being developed and used in some countries, depends upon a professional judgment by a (more) senior colleague – would they trust the trainee to execute the capability safely without needing support? The standard is obviously relative, and everyone will need (and should seek) support with a challenging or difficult case.

Judging entrustability also requires the collection of structured evidence from a variety of senior people, in a variety of settings and with a variety of patients. It takes time and effort. It is not a realistic method of measurement on a large scale.

On the other hand, capabilities are high-level skills and are not amenable to assessment through written examination, or a brief (20-30 minutes) observation of a professional.

One solution is to use the levels used for competency, which are rather more closely defined and could (probably) be completed by three or four observers independently over a period of four weeks. A table illustrating a grading or measure of competence is below.

LevelExit descriptors: 
at this level the person
A
Has observed, and has performed under supervision.
Has adequate knowledge of the process. Undertakes the whole process with supervision. Performs some parts of the process with reasonable fluency
B
Does simple cases fluently; has supervision and support.
Knows the whole process, the evidence and the reasons that underlie it. Carries out a straightforward process fluently from start to finish. Demonstrates judgment on when to seek advice from the supervisor (knows own limitations).
C
Completes most cases; distant supervision usually, with direct help rarely.
Adapts to common variations encountered in the process (a skill), without direct support. Recognises and analyses correctly common difficulties encountered during the process. Manages most of the common difficulties. Knows and demonstrates when help is needed. Usually requires advice, not hands-on support
D
Competent alone, including managing unusual events
Manages both straightforward and difficult situations to a satisfactory level, without external input. (a skill). Competent to the level of an independent rehabilitation practitioner. Supervises trainees.

The advantage of a simple measurement such as this is that it allows people to acquire a level of competence appropriate to their level of responsibility. For example, many healthcare assistants in a rehabilitation service could easily acquire level A capability. Once achieved, it would be something they could use to apply for a higher grade post in rehabilitation. More importantly, a rehabilitation service should aspire to help all staff of any grade to acquire level A in at least some capabilities. It would be an indicator of higher quality service.

This page has set out a proposed seven capabilities that any person involved in rehabilitation should have. It also sets out a measurement or grading system which could be used to recognise that anyone working in a rehabilitation service can acquire some specific rehabilitation competence. More detail about these capabilities in practice will (in due course) be provided on other pages. Moreover, with a little modification, these capabilities can also be used as features one a service that has rehabilitation expertise.


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