Training in rehabilitation
Last modified: January 14, 2026
“How should we organise training in neurological rehabilitation?” I have recently been asked to give a webinar on this. This post considers the essential rehabilitation expertise needed in all areas of rehabilitation, and how it should be taught and evaluated. It will do so from first principles, starting with an outline of the core skill required in all rehabilitation. As rehabilitation is a team activity, the output of my discussion will apply to all professions. The underlying assumption is that the essence of rehabilitation is the same across all branches of rehabilitation. I answer the question at the end.
Table of Contents
Preface
Rehabilitation professionals generally focus on solutions and the actions they can undertake. This is an example of “the law of the instrument,” succinctly summarised by Maslow in 1966: “it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.”
This post emphasises that training must focus on high-level rehabilitation expertise, so we practice what we preach and become holistic, truly patient-centred professionals rather than merely competent at selecting and delivering specific treatments.
Introduction
Healthcare education and training have evolved from apprenticeship through straightforward academic studies to supervised, directed clinical practice with continuing professional development. The assessment outcomes shifted from academic exams to clinical assessments of competency in specific tasks. The focus on competencies culminated in a rapid proliferation of competencies, with a corresponding lack of attention to the crucial clinical skills of communication, setting priorities, and considering the situation holistically.
UK medical training.
In the UK, this trend was reversed by the General Medical Council through two major strategic changes. The Shape of Training, published in 2013, recognised that the move towards specialisation had progressed too far and did not meet the needs of most patients who had multiple diseases, were old, and needed doctors who could analyse, understand, and manage patients with complex multimorbidity.
The GMC also revised its approach to the postgraduate training of doctors, as outlined in Excellence by Design – Standards for Postgraduate Curricula. The GMC abandoned competencies as a measure of medical training and focused on higher-level outcomes. One of many requirements was CR1.4: “Specify the high-level outcomes so it is clear what capabilities must be demonstrated, and to what level, to complete training.” Two examples of possible high-level outcomes are the ability to run an outpatient clinic efficiently and effectively and to work with multiprofessional and multiagency teams.
Postgraduate medical curricula were radically changed, focusing on six generic outcomes for all doctors and 6-8 specialist outcomes determined by the speciality. Subspecialty training was minimised, to be acquired, if necessary, once in a senior post.
Rehabilitation training.
Rehabilitation faced a further specific challenge. Most professions and specialities focus on disease and operate within a biomedical framework. Rehabilitation focuses on disability within a biopsychosocial framework. A rehabilitation approach is fundamentally different, yet this has not been recognised. The medical profession is the only one trained in rehabilitation, yet it still places undue emphasis on biomedical aspects.
The first challenge is to acknowledge that expertise in rehabilitation must be an addition to the professional expertise of all professionals working in rehabilitation.
A further challenge arises from the scope of rehabilitation, which benefits most people with significant, persistent difficulties that limit their activities, regardless of the cause, the person’s age, the stage of the disorder, or the setting in which rehabilitation occurs. No one can be a specialist in all potential situations; training is intended to ensure that all practitioners have rehabilitation expertise to supplement their specialist skills.
The third challenge is to recognise that a professional, a team, and an organisation must combine expertise in the critical aspects of rehabilitation with specialist clinical expertise appropriate to the caseload of patients being seen.
Last, we must design rehabilitation training that applies equally to all professions, rather than having separate training for doctors, nurses, social workers, psychologists, and so on.
The first step: key features of rehabilitation.
Unfortunately, rehabilitation means different things to different people. Moreover, the elision of Physical Medicine with Rehabilitation has seriously increased confusion, as it combines Physical Medicine, an ill-defined biomedical approach, with Rehabilitation, making it akin to referring to Physiotherapy and Rehabilitation together as a single expertise.
Rehabilitation facilitates and catalyses a person’s adaptation to their malady, a generic term covering all people who attend health services for help. This reframing of rehabilitation as a service facilitating an inevitable and normal process, rather than as a treatment, is the primary innovation in the General Theory of Rehabilitation. I give more details about the theory here.
Rehabilitation occurs in the framework of the holistic biopsychosocial model of illness. This is the second significant component of the General Theory of Rehabilitation. Rehabilitation has used a biopsychosocial framework for 45 years but has not fully embraced the consequences of the model. Rehabilitation could be considered one branch of biopsychosocial healthcare, just as surgery is one part of biomedical healthcare.
These two features apply across all rehabilitation. They lead to the concept of rehabilitation thinking as the unifying expertise; it is a cognitive approach with a holistic scope, centred on the person, and grounded in a systematic, evidence-based clinical problem-solving framework. I have also published posts about rehabilitation thinking. The professional must draw on their professional knowledge and skills in this context, using them within an overarching rehabilitation framework.
The two figures below illustrate the service consequences of the General Theory of Rehabilitation and the essential features of rehabilitation thinking.
The second step: high-level outcomes.
The concept of high-level outcomes, sometimes called entrustable capabilities-in-practice, is vital to modern training and its evaluation. These apply mainly to individuals who will practice autonomously, without routine professional supervision or guidance. However, one must recognise that a true expert knows their limitations and when to seek advice or support. Furthermore, almost all healthcare is delivered by teams that inevitably provide support and informally monitor performance.
High-level outcomes involve sustained, complex activities, such as managing an emergency medical or surgical take, analysing a complex rehabilitation patient to provide a detailed formulation and a rehabilitation plan, and working as part of a team on a ward. They depend on multiple skills, extensive knowledge, good communication, judgement and the ability to prioritise.
Evidently, these capabilities cannot be examined or measured directly. Nonetheless, they can be judged based on multiple independent reports on a person’s performance, judgments made by professional colleagues on the team, and not solely from the person’s profession. The ultimate question is, “Would I trust this person to be safe and effective in most foreseeable situations with direct supervision?” The concept is called entrustability.
A key part of the assessment is the use of indicative behaviours. One assesses how someone behaves in their job; there is no examination under standard conditions or by standard observers. Second, one studies only a minority of possible activities or behaviours. The assumption is that satisfactory performance in a range of behaviours is likely to indicate satisfactory performance across the board. For example, someone who manages an unexpected event halfway through an activity will likely manage the whole activity well.
The third step: generic capabilities.
The UK General Medical Council (GMC) reviewed complaints made against doctors and found that most significant complaints concerned their professionalism, not their clinical knowledge or skills.
Their response was the development of the Generic professional capabilities framework, which outlined nine key skills covering the behaviours that cause most complaints. Thus, when redesigning the medical curricula, they introduced formal assessment of generic capabilities that all doctors must meet. These capabilities should be required of all healthcare professionals.
The original document identified nine areas of interest, but for the curriculum, these were reduced to six. The generic capabilities are outlined in the Rehabilitation Medicine curriculum.
I adapted these, improving clarity and consistency and adding one on maintaining professional standards, which was assumed but not required by the GMC, when I proposed training for all professions. I published a paper, What attributes should a specialist in rehabilitation have? Seven suggested specialist Capabilities in Practice, and I have enlarged on them on this site, starting here.
The proposed capabilities are that all (rehabilitation) professionals should:
Function within the healthcare and social support management systems.
They need to understand the healthcare system(s) and, increasingly, the social support system(s) in which they work. This helps them work within their system to negotiate access to appropriate resources for their patients, both within and outside the healthcare system, and to explain matters to their patients. Most patients receiving rehabilitation will also use social care and non-statutory services to meet their needs.
Adapt actions to the social context of their patients.
They must consider the patient’s social context. Some aspects are very personal, such as family values or cultural rules, while others are very general, such as legally defined practices or local cultures.
All rehabilitation actions relate to the patient within their social context. The team must be aware of the common social contexts among their patients, such as religious beliefs, attitudes towards disability, and local cultural norms. All decisions, actions, and goals must be concordant with the patient’s social milieu.
Communicate effectively, including when sharing decision-making.
All healthcare professionals need to communicate effectively. This does not mean simply giving someone information. It encompasses active and empathetic listening, non-verbal communication, writing informative letters or referrals, the use of various technologies such as phones and video conferencing, the style of interaction, and more. Failures in communication underlie many complaints and episodes of harm to patients.
Rehabilitation specialists also need to recognise when a patient has difficulties affecting communication as part of their illness, such as reduced hearing, language impairment (aphasia), cognitive losses, attentional difficulties, delusional beliefs, and more. Moreover, rehabilitation professionals must be skilled at communicating with people who have communication difficulties.
Focus on quality and safety, and participate in quality improvement systems.
They must focus on the quality and safety of their own work and of the service or team they work within. This concern means giving effective treatments and avoiding harm, and extends to many other matters affecting service quality, such as being respectful of others. There is also a responsibility to comply with and actively participate in any quality control and monitoring systems.
Rehabilitation specialists additionally should consider activities and services occurring outside the local rehabilitation service. Patients will be in contact with many services which may be provided by social services, non-statutory, not-for-profit organisations, and commercial organisations. Much of the observed harm in rehabilitation arises from poor communication and collaboration between services. services and/or a lack of collaboration; this must be recognised and acted on.
Understand and support research.
They must understand research and be able to evaluate it. They should be able and willing to support research. Engagement with research fosters curiosity, critical thinking, a willingness to change and adapt, and increased collaboration with others.
Rehabilitation specialists should focus particularly on the functional and social outcomes of research rather than on physiological outcomes. They should encourage the use of patient-reported outcomes whenever the opportunity arises.
Teach and supervise healthcare trainees.
They have a responsibility to help teach and train others, even if only by supervising someone who has just started. Most people also teach and train colleagues as a normal part of their day-to-day work; a few undertake more formal teaching.
Rehabilitation specialists should specifically teach training-grade professionals from outside their own profession. Effective teamwork depends on each person being aware of the knowledge and skills of other team members.
Base all clinical practice on best available evidence, and on professional standards.
This encompasses (a) keeping up to date with relevant knowledge and skills, usually referred to as continuing professional development, (b) applying that knowledge and skill to all aspects of clinical practice, and (c) seeking out relevant evidence and using it when faced with a new problem or other uncertainty.
Rehabilitation specialists need to participate in multidisciplinary learning with other professions to enable better-coordinated care. They also need training in multi-professional teamwork, such as undertaking rehabilitation interventions with others and setting team goals. This requirement contrasts with the uni-professional focus of most continuing professional development activities.
The fourth step: expert rehabilitation capabilities.
The Rehabilitation Medicine curriculum set out eight capabilities that would ensure the doctor’s expertise could be applied to rehabilitation in any likely clinical situation. It emphasises rehabilitation as an approach rather than a series of specific treatment techniques or competencies.
The eight capabilities can be reviewed in the curriculum. In my revision for any rehabilitation professional, I generalised the two more medical capabilities into one focused on maintaining and improving profession-specific knowledge and skills. I also improved clarity and adjusted capabilities to be more appropriately phrased.
The proposed capabilities are that all expert rehabilitation professionals should:
use the biopsychosocial model of illness in all areas of practice.
This encapsulates one of the central distinguishing features of rehabilitation, the need to take a holistic view of a patient’s situation. It requires anyone specialising in rehabilitation not only to know the biopsychosocial model but also to use it across all spheres of work: direct patient care; academic activities such as teaching and research; management activities such as monitoring and improving service quality; financial activities such as quantifying and justifying resources; and bureaucratic activities such as organising clinical records or information.
In clinical practice, patient formulations, planning, intra-team communication, notes, and all clinical documents should be set within this framework.
develop (with others) a complete rehabilitation plan for the patient.
Using the biopsychosocial model requires a willingness and ability to consider how all the patient’s identified needs may be met, including those well outside the professional’s or team’s expertise. The professional (and team) should identify and refer patients to the resources needed to meet these other needs. Their responsibility is to ensure all needs are met, not to meet all needs themselves. The professional should identify priorities among the many possible actions and goals.
When the professional is the patient’s first point of contact for rehabilitation, they should identify the main interventions or further assessments likely to be needed and prepare an outline plan. Rehabilitation specialists must acknowledge that “no problem is an island entire of itself; every person’s problem is a piece of a greater whole”; they must develop a complete outline plan, not just their part.
work as a full and equal member of any multi-disciplinary team.
Rehabilitation problems are complex, and a collaborative team with diverse knowledge and skills is the best approach to them. It requires individuals to relax the boundaries around their unique professional training, share their expertise, help other team members acquire relevant skills to support their interventions, and be prepared to assist with those interventions.
I have discussed teamwork in rehabilitation. It requires each member to: give positive attention to achieving good teamwork; show commitment to the team and treat others with respect; be prepared to both lead and be led; appreciate the knowledge and skills of other team members so that they can develop and then work jointly on agreed goals; and support interventions designed by others, especially the common ones.
work across organisational and geographic boundaries, collaborating with other professionals and teams.
It will be rare for a particular rehabilitation professional, team, or service to resolve all patient problems without any input from others. Transferring responsibility to another team is also common. Teams and team members need to be willing to work closely with others outside their own service, sharing information and work. Often this will involve training others, professionals and family/friends, how to help or support the patient.
The rehabilitation expert will: actively identify and work with other professionals outside their own service; liaise with and teach others as needed to help the patient; and pass on all relevant information within the rules governing confidentiality. Failure to pass on information poses a significant risk to the patient and wastes resources.
recognise, accept and manage uncertainty and complexity, with long-term commitment to the patient if needed.
Patients needing rehabilitation have complex, long-lasting problems. This is associated with: uncertainty about the future and whether an intervention will help; involvement of multiple teams and organisations; failure to identify and manage all problems; and failure to maintain a continuing rehabilitation-professional interest.
The rehabilitation specialist needs to acknowledge this complexity and uncertainty, and clearly explain them to the patient and others. The rehabilitation specialist also should recognise when a patient and, often, their family are struggling with the multitude of people and services. After discussion with others, they should be prepared to provide long-term rehabilitation support, not limited to their own professional expertise.
support the common, generic rehabilitation interventions.
Every rehabilitation specialist must be familiar with the typical interventions used by other team members with their patients, sufficient to provide basic input and, with support and training from others, to support more specific interventions safely. Conversely, the rehabilitation specialist should support other professionals in implementing their own interventions.
use profession-specific expertise to help the patient and assist team processes.
Each team member will have a body of knowledge and skills that others within the team do not have. Blurring of boundaries does not require a complete loss of uni-professional expertise. Indeed, maintenance of unique expertise is vital.
The professional with rehabilitation specialism will undertake a detailed assessment of factors relating to their specific professional expertise, and then explain the significance and impact of their findings in the context of all other information. They should contribute to the analysis and understanding of the patient’s situation.
The professional with a rehabilitation specialism will also: provide a more accurate prognosis for matters within their area of expertise; identify which profession-specific interventions might assist and how; explain why any other suggested interventions will not assist.
The last step: adjusting professional learning to patient needs.
When developing the British Society of Physical and Rehabilitation Medicine’s guideline document, “Rehabilitation and Complex Disability Management in Specialist Nursing Homes and Other Residential Units – Guidance to Best Practice,” we were forced to consider how we should ensure both a high standard of rehabilitation practice and a high standard of professional clinical expertise in each of the myriad specialist clinical services.
For example, rehabilitation is needed by people with challenging behaviour after brain injury, who have severe cognitive losses and high dependence, who are unconscious and using a ventilator, or who have a severe psychosis. In each case, the clinical competencies needed are crucial to ensuring patient safety, but they differ hugely. The same rehabilitation expertise is needed in each situation.
We resolved this dilemma by adapting the concept of capabilities to apply it to the clinical service, adding one to ensure the service had the appropriate knowledge and skills to provide care and effective rehabilitation for the expected patient caseload.
A similar requirement is implicit for every professional: they are responsible for meeting their clients’ needs. For example, an accountant advising self-employed healthcare professionals running private services will have an entirely different expertise to an accountant advising a middle-sized charity, but both have accountancy expertise.
These capabilities have been published in a paper, Does a service provide safe, effective rehabilitation? An evaluation method for providers and purchasers.
The proposed capabilities are that the service:
Uses the biopsychosocial model of illness throughout the service.
The biopsychosocial model of illness is a defining characteristic of a rehabilitation service. Everyone, including non-clinicians, should use it in all aspects of their work.
Use a multi-professional team able to meet 80% of patient needs.
A multi-professional team is central to effective rehabilitation. The core team should be able to manage 80% of clinical problems seen in the service, and there should be procedures for obtaining extra help needed
Develop a person-centred rehabilitation plan for each patient.
The team must document each patient’s formulation and rehabilitation plan, ensuring they are person-centred.
Work collaboratively across organisational and geographic boundaries.
Other services will inevitably be involved with most patients seen, and a rehabilitation service should work flexibly and collaboratively with all other agencies and services in different settings if needed.
It should be part of a local rehabilitation network, so they can also approach other services for help with problems or solutions the team cannot manage from its own resources.
Provide rehabilitation interventions tailored to the person’s needs.
Effective rehabilitation involves multiple interventions tailored to the patient’s needs; the service should not have pre-defined treatment packages. The service should consider published evidence and guidelines when selecting interventions.
Ensure staff have the competencies needed for their patient caseload.
A service must ensure staff have the knowledge and skills to maintain the patient’s safety and well-being (meet their care needs) and to provide effective treatment (meet their rehabilitation needs).
Acknowledge and manage uncertainty and complexity.
Every patient’s situation is complex, and rehabilitation is a complex process with multiple interventions. Consequently, uncertainty and complexity are hallmarks of rehabilitation. The service must recognise and manage this, for example, using a local peer support network.
The crucial feature of this system is that the service must match its competencies to the patient caseload. The service is expected to:
- Define the patient caseload it can accept and manage.
- Select between three and six high-level indicative competencies to cover
- The care needed by the patients, and
- The rehabilitation interventions required.
- Demonstrate that they have the indicative competencies:
The figure below outlines the steps a service should follow; the method is shown in the top right, and the competencies are referred to in the bottom right box. This document provides example competencies from the BSPRM guidance. You will notice that the competencies are heavily skewed towards inpatient neurological rehabilitation services.
Training in neurological rehabilitation.
The approach I have espoused is to train professionals in rehabilitation as an addition to their professional training. I have also suggested that this applies equally across all branches of rehabilitation. I maintain this stance because all complex cases require a strong rehabilitation approach, and complex cases arise in all branches of rehabilitation.
Nonetheless, rehabilitation for people with brain disorders is usually more complex than for people with non-neurological disabilities, not least because the brain is central to the processes of adaptation and learning, which are crucial to rehabilitation. Other reasons include the perception that a brain disorder directly challenges the essence of self and usually affects sensory or motor function. Third, in many instances, the person may superficially appear well, and both healthcare professionals and members of the public may dismiss, disbelieve, or devalue the challenges the patient faces.
Complex problems are also common in people with psychiatric disorders, congenital brain damage and learning disabilities, and other disorders of neurological function, including functional disorders. These patients place the greatest demands on health and social care budgets. Rehabilitation may significantly reduce long-term costs, but success depends on the rehabilitation team having sufficient expertise to analyse the situation, understand the prognosis and potential interventions, and plan a strategy to optimise social and physical functioning.
The training I have outlined should ensure that appropriate rehabilitation expertise is provided. However, disordered neurological functioning encompasses neurophysiological and neuropsychological dysfunction; they are inseparable. Consequently, all professionals involved in rehabilitating people with neurological dysfunction require a sound understanding of basic neuroanatomy, neurophysiology, and cognitive and emotional neuropsychology. This will usually be achieved by working in neurological and psychiatric services while training.
The crucial point is for the professional to ensure they have the neurological, to include neuropsychiatric and neuropsychological knowledge and skills required for the patients they see.
Conclusion
I have shown that:
- A consistent operational characterisation of rehabilitation can be applied across all professions working in rehabilitation services and to the services that employ rehabilitation professionals.
- The high-level outcomes for professionals and services include a responsibility on the professional or service to ensure they have appropriate expertise in the clinical caseload they see, to deliver an effective and safe service to patients.
- In all cases, evaluation depends on the person or service demonstrating behaviours indicative of adequate expertise rather than relying on examinations or external standardised assessments.
This post answers the question posed, “How should we organise training in neurological training?”, by emphasising the importance of:
- Structured training in the essential expertise of rehabilitation, which should be the same for all domains of rehabilitation and all professions,
- Professionals and services are responsible for ensuring all professionals in a team have or acquire the knowledge, skills, and experience needed to manage the patients being seen.
Evaluation of professional expertise ultimately requires trust. Indeed, the whole healthcare system must be built on trust. This was highlighted by Onora O’Neill in A Question of Trust, the BBC Reith Lectures 2002. She has applied her ideas to business corporations in Trust, Trustworthiness, and Transparency, which is appropriate given the increasing fragmentation of the UK National Health Service. Without trust, we can achieve nothing collectively.
