Capability 5: complexity and uncertainty

Uncertainty is an inevitable consequence of using the holistic biopsychosocial model of illness as the analytic framework in rehabilitation. This arises from complexity, best defined as the presence of multifactorial, non-linear relationships between different factors, such that the outcome of changing one item upon another item often cannot be predicted accurately. For example, the effect of recommending progressive resistive exercise of the legs upon a patient’s walking endurance cannot be predicted with certainty, because factors such as motivation, concentration, associated sensory functions, the availability of mobility aids, mood and fatigue may also all affect the outcome. The exercise itself may reduce fatigue and improve mood, or may increase fatigue and cause pain, this reducing motivation. The most complex cases will additionally be influenced by ethical considerations, legal considerations, and difficulties in accessing resources. The expert in rehabilitation has to be able to negotiate all these issues and come to a justifiable course of action. A Mind-Map to look at while reading (and download) is here.

Context – the biopsychosocial model

Rehabilitation wishes to be holistic and to be patient-centred. Satisfying these wishes requires the use of the biopsychosocial model of illness. It is the only available model that will satisfy both wishes. Its central characteristics are:

  • it identifies an infinite range of factors which can influence the patient’s situation, grouped into eight domains in the version of the model used on this site;
  • the relationships between factors are
    • often non-linear
    • often bidirectional
    • often influenced by one or more other factors

These characteristic lead to (mathematical) complexity and the characteristics of complexity are that:

  • identifying causal links is rarely easy, and often impossible
  • predicting the influence of changing one factor is usually difficult and uncertain

Therefore it is hardly surprising that rehabilitation necessarily has to manage uncertainty in almost all spheres. The surprise, perhaps, is how much prediction can be made.

The complexity and uncertainty varies according to the outcome one is considering. If one is considering whether a 25 year old woman whose leg was amputated below the knee following direct trauma, with no other injury, will walk with a prosthesis, then prediction is easy (yes). But if one is considering whether she will be able to return to work, or whether she will return to previous leisure pursuits and maintain social networks, there are very many more imponderable factors to consider, including her ability to adapt.

Uncertainty within the rehabilitation process

It is important to remember that rehabilitation is a problem-solving process, and many problems faced by people and by organisations are solved by ‘trial and error’; a possible solution is tried, and if not successful enough, another solution will be tried. Prediction is difficult in most areas of life, outside healthcare. The Covid-19 pandemic has demonstrated that, but predicting the cost of a large project is also too complex for a government to achieve.

Sometimes it is known that a solution might work, but the only way to know is to try it. If the problem is to reduce the chances of some specific event happening, and if the event is random and not very frequent, then it may take time (and careful analysis) to know if an intervention is helping. Last, if the outcome of interest is subject to considerable fluctuation, then again careful measurement and analysis may be needed to detect benefit or harm, or no effect.

Therefore, when considering rehabilitation, practitioners, patients, family members and funders all need to understand that trials of treatments are an important part of all rehabilitation and that outcomes often cannot be predicted with any certainty. Sometimes the likelihood of success can be estimated.

Trials of interventions

The most important consequence for the rehabilitation team, and for the individual members of that team, is that, while it is important to start a trial of a possible treatment, it is even more important to stop a treatment when it is not succeeding sufficiently to justify continuation. In practical terms this requires:

  • identification of a measurable outcome that is the target
  • agreement by both the patient (and family) and the team on
    • how long a reasonable trial should be
    • what constitutes sufficient change to warrant continuation
    • that treatment will stop if treatment fails
  • discussion of options to be considered if treatment fails

A trial should not start unless these five requirements have been met, because it will be (a) difficult to know if success is achieved, and (b) difficult to stop even if evidently not succeeding, because no plan exists and hope will drive continuation.

In summary, use of the biopsychosocial model of illness leads inevitably to complexity and uncertainty, particularly when considering higher-level functional and social outcomes. As rehabilitation is a problem-solving process, the only practical way of handing this is to offer structured trials of treatments, with clear rules governing stopping. This is fair to the patient, who has an opportunity to benefit, and to others as resources will not be used pursuing treatments that are not benefiting a patient.

Behaviours

The professional needs considerable self-confidence to show the required behaviours, because both patients and the professional him- or herself wishes to feel confident and certain. It is uncomfortable to admit doubt and uncertainty. This discomfort can be lessened considerably using the trial requirements outlined above. Setting out a plan with ‘what if’ already covered makes both the professional feel in control, and the patient feel that there is a path to follow, even if the exact path is uncertain.

For this capability the professional:

  • acknowledges the level of uncertainty present in all formulations and decisions. This help both the professional and the patient to accept that uncertainty is the normal state of affairs;identifies the major factrs that are contributing to the uncertainty
  • puts reasonable bounds around the range of uncertainty, avoiding the temptation to be over optimistic at the better end;
  • explicitly identifies the major factors contributing to the uncertainty;
  • uses formal trials of treatment to reduce uncertainty and to satisfy everyone that reasonable possible interventions have been tried;
  • makes decisions despite the irresolvable uncertainty, and does not either avoid making the decision or pass it over to anyone with less expertise;
  • formally documents in the clinical record the uncertainty, the factors causing it, and the reasoning for the decision;
  • explains to the patient and family the uncertainty, the factors causing it, and the reasoning for the decision;;
  • considers the legal and ethical aspects of the situation in any very complex and difficult case;
  • seeks advice and help from team members, professional colleagues, and if necessary external experts when needed, delaying making a decision to do so.

Two common themes underlie these behaviours.

The first is that the professional is simply being more considered and careful in making a decision that is more difficult. These behaviours are similar to those applying when making any decision, but they need to be exaggerated.

The second is that the profession prepares both him- or herself by normalising uncertainty, pointing out uncertainties at every opportunity so that this is only different in extent. If tis approach is undertaken by all professionals within the team, then patients and families will also feel that it is a normal state of affairs, just a litte larger than usual.

Knowledge and skills

Managing complexity and uncertainty depends more upon skill than knowledge; knowledge tends to reduce complexity and uncertainty.

However, the professional should be aware of what is known or discoverable. In other words, the professional needs to distinguish between managing uncertainty where that certainty can be reduced through further investigation or through taking time to find the information, and true uncertainty where further investigation or searching will not materially reduce the uncertainty.

Therefore the professional does need extensive general clinical knowledge, particularly of what is knowable – and how to discover that information. This will reassure the professional personally and will reassure others that there is true uncertainty rather than the individual being uncertain through ignorance.

The other class of knowledge is personally acquired knowledge, referred to as experience. A professional needs to the able to evaluate their own experience and to be able to judge how dependable it is as a guide when applied to the current situation.

Thus the expert rehabilitation professional should know:

  • what is known, even if they do not know it for themselves, and how to find the detailed information;
  • what they have learned from their own experience, and how to judge its validity;
  • the factors that determine prognosis, both in general across most situations, and any particular prognostic factors for common conditions;
  • the legal framework appertaining to managing risks such as preserving the safety of a vulnerable adult;
  • an ethical framework or approach to use in complex, uncertain cases;
  • when and how to seek advice from others.

The skills needed are similar to those needed in day-to-day practice, except they are needed at a higher level and must be maintained under stress.

Thus the primary, overarching skill needed is to be able to maintain a full professional approach, using all knowledge and skills, in situations which can be challenging, stressful and often emotional.

The other skills that an expert rehabilitation professional needs are to be able to:

  • use the knowledge they have acquired through experience appropriately;
  • formulate a case fully, including when relevant all legal and ethical aspects;
  • use trials of treatment effectively as a way to reduce uncertainty;
  • explain in a clear and logical manner the facts used, the analysis and reasoning undertaken, and the decision;
  • accept, respect and listen to contrary views and/or new information;
  • modify a formulation, and change a decision in the light of new information or suggested new analysis and reasoning, when it is appropriate to do so.

In summary, the capability is demonstrating an ability to perform rehabilitation at the highest professional level, under circumstances that can be challenging and stressful in many ways: personally, intellectually, emotionally, inter-personally. A Mind-Map summarising it is available here. It requires considerable insight into the limits of the person’s own knowledge, but also an insight into the value of the person’s own strengths and experience. When successfully applied, it can transform a situation. But often transformational success is not possible, and the goal should be establishing stability and understanding for all concerned, recognising that the situation is as it is and that the plan proposed is the least unsatisfactory solution.

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