Improving rehabilitation practice: do we just need more training?
The world’s population older than 60 is set to double in the next 30 years. Many of these people will be living with chronic diseases that require support. The World Bank estimates 15% of the world’s population live with disability, and a fifth of those with severe disability, with the number requiring assistive and rehabilitation assistance growing. This represents a significant challenge for health systems around the world.
The Nossal Institute for Global Health is working to integrate rehabilitation services and assistive technologies within health systems around the world. This complex undertaking is the basis of the USAID funded ReLAB-HS project we are co-leading with the Johns Hopkins International Injury Research Unit at the Johns Hopkins Bloomberg School of Public Health.
In Uganda, Ukraine, Myanmar and Pakistan, there are very few health workers trained in rehabilitation, and few opportunities for rehabilitation training or professional development. As part of the five-year project, we will be working with consortium partners to improve rehabilitation systems in these countries.
One key aim of the ReLAB-HS project is to promote the competency and capacity of the rehabilitation workforce. A critical component of this is skills acquisition and training. Yet, while training can be inspiring and even transformative at an individual level, more training, or better training, does not always directly translate to improved practice. It is therefore crucial to understand the features of the working ecology that enable or constrain the adoption of new rehabilitation approaches introduced during health worker training and continuing professional development (CPD).
So, what do we mean by working ecology?
Well, a worker is not a petri dish in a laboratory. In a laboratory we can isolate elements and look at the impact of adding or removing different factors. In a real-world setting, we don’t have this option; a worker’s behaviour is subject to a range of environmental (or ecological) influences. Ecological models or social ecological theories commonly explore influences at the individual, interpersonal, organisational, community, and policy levels, while accounting for how these different influences relate and interact as they influence behaviour.
What does this mean for understanding the competency and capacity of health workers?
Principally, that they are individuals, but also members of communities that influence them. They have different motivations, aspirations and experiences that are socially formed and negotiated within their homes, communities, and places of work. These all have a bearing on what they do now, and how they may act in the future. There are, for instance, a range of influences at individual and environmental level that impact whether training will improve worker capacity, and ultimately, practice. These include the mode of training delivery, the learning styles and experience of training participants, and crucially, the capacity of those tasked with delivering the training to do it well.
Importantly, workers will also experience variable levels of system support prior to, during and post training. This may include whether they receive appropriate and reliable supervision, a consistent supply of needed materials, their agreed remuneration on time, a job description, or the opportunity to work within a governance and policy environment they feel supported by. All may influence whether they feel the work they are being asked to do is needed, justifiable and therefore worth doing. They will also work in a context where their co-workers, as well as the people to whom they deliver their services, value their contribution to varying degrees. This ‘demand’ for their work can be motivating and help justify their efforts to themselves, their colleagues, and their managers. But its absence can adversely impact all these things.
We are reviewing the key features of the working ecology likely to impact the translation of rehabilitation training into practice. We will use this review, in combination with the knowledge gap analyses produced by our in-country partners, to collaboratively plan the way forward towards understanding the pathway from training to improved and sustained rehabilitation practice. Our first priority is to capture the context specific experiences and insights of stakeholders identified by our country partners.
The enablers and constrainers of success when integrating rehabilitation and assistive technologies into health systems will be specific to each setting. The actors and the outcomes will be site specific, but the process we follow to build consensus around priority focus areas will, in each setting, involve collaborative stakeholder engagement. Understanding workers in their context and within their working ecology is key. The health system is, after all a human system. If health workers are being tasked with new responsibilities, unlocking the meaning this has for them within this ecology is critical. If we don’t do this, investing in training, no matter how well developed, may be in vain.
This article was written by Dr Daniel Strachan and Kirsty Teague.
Read more about Nossal's role in the ReLAB-HS project
Dr Daniel Strachan