Rehabilitation professions.

Team members face an uneasy tension between being a member of a multidisciplinary rehabilitation team and being a member of a professional group. On the one hand, they have a special expertise in and commitment to rehabilitation. On the other hand, they have a special expertise in and commitment to the activities of their profession. This tension underlies research into the contribution of a particular profession within rehabilitation.

For example I have seen, as submissions to Clinical Rehabilitation or published:

• a systematic review of ‘physiotherapy treatments‘ for chronic pain;
• a systematic review of ‘rehabilitation nursing interventions‘ to increase self-efficacy after stroke;
• a systematic review of ‘occupational therapy‘ in multiple sclerosis.

Several questions occur to me:

• what distinction is being drawn between “being seen by a physiotherapist”, which is much more than simply having therapy, and “receiving physiotherapy”?
• what are the boundaries that distinguish, clearly, absolutely and in all settings interventions by (for example) physiotherapists and nurses or doctors? Indeed are such distinctions possible?
• last, given that rehabilitation (in common with almost all healthcare) is a team activity, how is it going to be possible to disentangle the effect of one member of the team?

In this blog, I explore these issues, starting from the premise that multi-disciplinary teamwork is one of the central, key characteristics of successful and effective rehabilitation. My conclusion is that a rehabilitation team is itself a complex system, which means that the questions are misconceived. This leads to a reformulation of team membership and structure focused on expertise, not profession.

Looking for differences in the contributions made by different professions assumes that professions differ. Do they?

The many healthcare professions involved in rehabilitation have much in common. They all have a designated title, protected by law, and individuals must be registered to use them. The professional organisation will have a set of professional standards, which set out qualification criteria and standards of practice and behaviour accepted.

Though I have not reviewed them, it is highly probable that the requirements of practice and behaviour are all similar: they will require practitioners to adhere to patient-centred practice, not to abuse their power etc. Indeed, many of the professions are regulated by a single regulator, the Health and Care Professions Council (HCPC), which suggests a single set of standards is applied.

The content of undergraduate education will also be similar. Each will cover topics such as human anatomy, physiology, psychology, and surrounding academic topics. Each will teach something about healthcare and the NHS, research, communication skills and similar important personal skills. Within each course there will be a focus on particular areas of relevance, such as movement science, and on some aspects of treatment.

It is probable that well over 50% of the knowledge and skills acquired by the time of professional qualification is shared across all professions; the only exceptions will be those professions who have more than three years of undergraduate education, such as doctors and clinical psychologists.

It is only after the first year of clinical employment that individuals are likely to start gaining more specific expertise, but it’s content will vary from person to person. Most of the specific expertise that an established healthcare professional has is accumulated during their post-graduate training, which varies greatly from person to person within a profession. Individual expertise diverges after gaining the qualification.

I conclude that, at the time professional qualification is attained, separate professions have more knowledge and skills in common than they have different. I also conclude that after qualification, post-graduate training gives further expertise but that, within a profession, different people learn quite different areas of expertise, and that this expertise is only loosely related to the particular set of knowledge and skills that defined the profession.

I will now use the example of back pain to discover whether it is possible to isolate a profession-specific expertise within rehabilitation. I will consider two professions: doctors, and physiotherapists. I will ask the question, can one identify a single approach or intervention that every person in one profession will use that no person in the other profession will use? Note: I am not asking if there is something that only members of one profession can or will undertake.

I am assuming two things. First, the practitioner considers him or herself to have sufficient experience and expertise to manage patients with back pain independently. Second, he or she is fully aware of the common, so-called ‘red flags’.

Among physiotherapists there are professionals who may suggest or even arrange imaging studies, will undertake detailed examination of movement, structures etc, and then offers massage and manipulation, or specific trunk strengthening exercises. Others may curtail examination, but ask much about social factors, work, alcohol, smoking etc and give advice and education, including general exercise. Yet others may offer cognitive behavioural therapy, or ultrasound, or a host of other treatments.

Among doctors, the range of investigations and treatments is greater, ranging from facet joint injections, operations, and other local treatments through drugs and advice on to pain neuro-science education, behavioural therapies etc.

So, the question is if comparing physiotherapy with medical care for patients with back pain, what is one comparing?

A similar analysis could be undertaken for almost any problem where two or more professions have something to offer, in isolation or as part of a team effort. Thus, for a patient with a particular problem, no profession has a unique treatment given only by the profession, and also always given by all professionals within that profession.

Rehabilitation is undertaken by a team, a group of individuals who share a common purpose and ‘worldview’ (of rehabilitation), and who work towards common goals with individual patients. The team will comprise individuals whose collective knowledge and skills can resolve most though not all the clinical problems seen. The team will also work towards its own goals for the team itself. For example a team might wish to gain expertise in a particular disorder, or group of patients.

Each individual team member will have specific areas of knowledge and skills which other team members do not have. But all team members will have, or will rapidly acquire, a range of shared generic knowledge and skills from other team members. The specific expertise may be related to their profession, but all professions share much knowledge and many skills, and the truly unique areas for any profession are limited.

More importantly, the specific expertise offered by someone from a particular profession is just as likely to come from general experience, and potentially several other team members could (or, indeed, do) have the same expertise. Moreover different team members have different personal characteristics that will give them particular expertise in managing some particular patients, perhaps through a shared interest in a football team, or books, or playing chess.

This view of the expertise an individual team member might offer to the team is illustrated here.

It also must be recognised that, within a profession, there is likely to be a very broad range go ‘unique’ expertise with little overlap between two individuals within a profession. For example, four occupational therapists from four different areas of work – paediatrics, adult psychiatry, wheelchair services, and acute medicine – will have much more in common with their team members than with each other.

Similarly, the shared knowledge and skills within teams varies. In a rehabilitation team, the shared knowledge and skills between professions concern rehabilitation; in a surgical team the shared areas will concern surgery; in an oncology team, oncology; in a psychiatry team, psychiatry, and so on.

In other words, the boundaries around any particular profession are loose and porous. Indeed, in a Venn diagram it is likely there will be much less overlap between two occupational therapists from different specialities than there is between team members within a team.

Nevertheless, a team may identify that they need a physiotherapist with physiotherapy expertise in the team’s clinical area of practice. They will probably select someone trained professionally as a physiotherapist, but their over-riding concern will be that he or she has the particular expertise needed.

In summary, each team member will have unique expertise within the team, not necessarily related to their professional training and expertise. This expertise is only a relative small part of the total expertise they bring to the team, with much of the expertise being shared rehabilitation expertise and expertise in the condition being treated. Further, their unique professional expertise will be quite different from other people from the same profession working in teams in other specialised areas of practice.

If a major accident occurs on a main road, almost immediately traffic will go along alternative routes. Only people in the immediate vicinity might not be able to travel. The system is resilient, resisting change and adapting to achieve its purpose.

Resilience, the ability to adapt to imposed change and still to function with near-normal effectiveness and efficiency, is a key feature of most complex systems. Examples abound: healthcare systems and the pandemic; car travel and major accidents on roads; electricity supplies and loss of a power station; a person who loses an arm.

If a team member is removed, there will not be much change detectable immediately. If all members of one profession were removed, it could still function but with a detectable loss of effectiveness. If a 50% of a team’s members were removed, it would still function at a lower capacity.

All losses will have immediate effects but they are usually small at the time. Over time the effect of missing expertise slowly causes loss of effectiveness and/or efficiency, other team members become more stressed, patients receive less good care, and occasionally harm arises.

By the same token, replacing a missing person, or adding someone to cover an area of missing expertise, will not have any immediate, detectable effect. But, assuming the gap identified was truly a gap, then over time the team will become more effective.

These phenomena can be seen in all organisations. If the chief executive is taken ill, the organisation functions satisfactorily for weeks or months. Slowly quality drops, direction is lost, mistakes arise. The same phenomenon applies at all levels, for example in the kitchens in a hospital; it is not the preserve of executive teams.

To conclude, teams are resilient, and can manage more-or-less satisfactorily for some time without individual members and, rather less well, without the specific expertise belonging to a specific profession. This is at a cost in terms of effectiveness, efficiency, increased risk to patients, and increased stress on other team members. Nonetheless, it makes it very difficult to identify the unique contribution of a team member or individual profession within a team.

A team can be considered in two different ways. The first is the usual, obvious one: a collection of individual professions working together towards common goals.

The second is less obvious. Consider a patient who needs: assistance relating to different ‘packages’ of expertise, such as education about self-management of the condition; retraining of a domestic skill; detailed assessment of high level cognition with advice on return to work; and advice on appropriate electronic assistive technology for communication.

Within the service it could be that: a specialist nurse and a physiotherapist both have expertise in teaching self-management of the condition; most occupational therapists (but not all) can teach cooking with only one arm; a speech and language therapist and an engineer specialised in assistive technology can both assess for communication aids; and only one psychologist in the team has experience of vocational rehabilitation.

The team chosen for this particular patient might have several different combinations of professions and still meet the need, but if another psychologist or occupational therapist had been chosen, the patient’s’ needs would not have been met.

Thus the appropriate team should be chosen not on the basis of a person’s profession, but on the basis of the individual people best able, between them, to meet all the needs a patient has. The choice needs to take into account other factors such as how great does the expertise need to be, and can one person fulfil several needs, thus making the process much more efficient.

This approach – mapping needs to team member and not to profession – is illustrated in the drawing here.

On a broader scale, this illustrates that a team is not just a combination of four (or any other number) people who each contribute a single separate pieces of expertise. A team is a combination of people, each with his or her own complex combination of strengths and weaknesses clinically, but also with their own combination of other important characteristics. The overall combination comprises a mixture of perhaps 10-30 different features. It will never be possible to know with any certainty which one, or combination of those factors actually makes the difference. Teamwork is a very complex phenomenon that, as a whole, benefits the patient.

In summary, any team, which is a collection of individuals who work together consistently over time on more than one project, is a complex system. Within the team there are multiple inter-relationships between individual team members as people, but also between areas of expertise. These relationships are often non-linear, and are affected by several or many factors, some of which may have bi-directional effects (feedback loops etc).

Members of any team, be it in rehabilitation, in a surgical operating theatre, or on an acute medical admission ward, have far more than one area of expertise related to their membership. They will have expertise relating to:

• their profession, which probably got them the job but is least important
• working in a team, often not taught but essential if the team is to succeed
• the conditions seen by the team, meaning the diseases or particular impairments
• the interventions offered by the team, both treatment and care
• interacting with other teams, including some outside health services
• processes, procedures, and policies used by the team
• jargon (words with special meaning) used in the team

Our training and education focusses primarily on the profession. Our naming of posts also focuses on the profession. But in rehabilitation, it is the expertise in the business of the team, and in functioning within a team that will determine success.

There needs to be a much greater recognition of the need to train in rehabilitation, and to learn about teamwork.

Within rehabilitation, doctors are not only the first profession to recognise the need for particular training in rehabilitation, we are also the first to place the specialisation before the profession, We are consultants in Rehabilitation Medicine. It is clear that we have a specialisation in rehabilitation. There are a few Rehabilitation Nurses (I believe) but one does not see Rehabilitation Physiotherapists or other professions.

To complete the accurate description of a post, or a team, or a service, one also needs to be informed about the area of expertise within rehabilitation – which may be around disease, or impairment, or around activities, or interventions.

To conclude, we need to changes names, descriptions, training, and services to recognise that rehabilitation is the purpose of many specialist multi-professional teams, and that all team members need training in rehabilitation, teamwork, and the condition or intervention the team specialises in.