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 the input of each individual therapist (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 this Mind-Map here.
Thirty years ago, at Rivermead Rehabilitation Centre, we had a patient aged about 17 years who had severe hypoxic brain injury. Among her many problems, she had flexor spasticity of 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: an 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 which will increase autonomy. There are two reasons for creating 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 amount of practice and feedback given in those 10 hours. It could and should also add additional practice and feedback throughout the rest of the day. In inpatient settings, nursing and care staff will play a central role; families may also contribute. In other setting, family members and any carers involved will be much more important.
Second, it is also well established that an environment that is stimulating and challenging increases learning and recovery, provided the person is able to explore it. Part of this environment concerns objects that may facilitate or hinder the person from exploring the environment. However, it is the social environment that has the bigger 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 risk?
The social environment is complex. Most patients receiving multi-professional, team-based rehabilitation in hospital will be in contact with between 10 and 20 individual people over a period of 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 many still be seen by many people from several or many difference 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 is different from hospital, much of the discussion and many of the 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 might better be termed management consistency, because it refers to everyone doing and saying the same thing, sharing an agreed understand of the situation and a uniform approach to its management. The paper adds that this includes information continuity, which again is really referring 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 suggested largely focuses on case management – identifying organisations needed and getting them involved – and coordination of work, through care planning. There is little discussion of how, in reality, any of the ideas proposed can be achieved. Furthermore, the report hardly considers consistency of management for an individual patient.
Although outside the scope of this capability, the idea of relationship continuity is important, and possibly an even more powerful component of rehabilitation. It is tangentially related to capability five. In complex cases that are managed over time by the rehabilitation service, it is the continued commitment to the patient by the team (not necessarily one person) that helps the patient 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. In that context, this capability applies to the rehabilitation team which will include nurses and care staff, and might extend to family members and any 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 and friends and all other people who are closely involved, 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 for managing common problems. The professional needs to engage in the development and implementation of these policies. Second, In all their own contacts with a patient, the professional needs to use and reinforce any treatments or approaches than can be used or reinforced safely. Third, the professional needs to teach both team members and others (e.g. family, community carers, community rehabilitation staff) the techniques needed to continue patient learning of skills.
In summary, this capability involves a mixture of learning basic approaches to a patient’s problems that lie outside the normal range of problems 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 an emphasis on ‘using the activity I need or wish to undertake as an opportunity to learn’.
The behaviours associated with this capability fall into two groups. The first group concern establishing a team-based approach to patients; in other words ensuring that the team will have a uniform, consistent approach patients. The second group concern applying a uniform, consistent approach towards an individual patient.
A group of professionals may consider themselves a team, and indeed 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 an approach towards every patient, and agreeing a common approach to problems commonly met.
From the patient’s perspective, the team need to have some of the characteristics of a person. Specifically, the patient needs to learn that all team members will react and respond in a similar way to the patient’s request or behaviour. The patient and family will mistrust a capricious team just as they will mistrust a capricious person. Therefore, the professional needs to initiate if necessary, and to participate in team discussions about how consistency will be achieved.
Ensuring a common approach towards a single patient is difficult. It depends upon using common approaches across all patients to common 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 patients and (b) to ensure that every person remembers and acts in the manner desired. Total consistency cannot be achieved. The greater the shared body of knowledge and skills within a team, the more likely it is that consistency will be achieved.
There is one area where consistency is needed, and can be increased, and that is in the interactions between the patient and their family members, friends who visit regularly, and personal carers (usually at home). Consequently, an important aspect of this capability is training others to have a consistent facilitatory approach.
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 policies are developed for all commonly faced problems within the service;
- Suggests evidence-based policies in professional’s own sphere of expertise;
- Ensures that policies within own area of professional expertise are in accordance with 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 important aspects to consider when agreeing an approach arising from own professional expertise;
- Follows the team’s agreed 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 end result of delivering a package of care that is consistent over time, across settings, and between individuals can only succeed if the professional has a body of knowledge that enables him or her to be consistent. While this does not extend to acquiring the professional expertise of all other professions, it does extend to have 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 main types of intervention used generally within rehabilitation: 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 policies and recommended approaches;
- 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 team.
The skills needed relate to the professional expertise of the person, and being able to use, adapt, and teach it in the context of 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 his/her own interactions with each patient;
- explain and justify management of other team members to the patient and 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 change in as many situations as possible. This should involve not only team members (including nursing staff for inpatients), but also all other people in regular, reasonably frequent contact with the patient – family, friends, carers, other rehabilitation teams or individuals. In this way the patients is no longer just have intermittent and relatively little rehabilitation, restricted to times when undergoing face-to-face treatment, but is living within a rehabilitation environment which encourages and allows practice anywhere and at any time.