rehabilitation and team work

7/26/2019 Rehabilitation and team work

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8 Section

REH ILIT TION

ND

THE

ICF

REH ILIT TION

There are many definitions of rehabilitation within the literature (Jackson

1984, Waters 1986, Wade 1990, Greenwood et al. 1993, Blackwell 1994,

Sinclair Dickinson 1998) bu t they all highlight similar defining attrib

utes of rehabilitation:

rocess Rehabilitation is generally described as being an active, dynamic, continu

ing process concerned with physical, social an d psychological aspects.

Steiner et al

2002

characterise rehabilitation as a continuous process

an d identify the rehab cycle , which aims to improve an individual s

health status and quality of life by minimising the consequences of dis

ease. The cycle consists of five stages:

Identifying problems an d needs

Relating the problems to factors that are limitingan d can be

modified

Defining target problems

an d

target mediators

an d

selecting

appropriate measures

Planning, implementing

an d

coordinating interventions

Assessing effects.

The last stage of the cycle may cause new problems and needs to be iden

tified, in which case the cycle begins again.

Restoration

In relation to rehabilitation, restoration involves enabling the individual

to regain lost elements of their life, such as physical functioning or per

sonal an d social identity. talso carries the sense of restoring the individ

ual to society or to a purposeful

an d

satisfying life. The use of the word

restore can imply that the emphasis of rehabilitation is on the individual

returning to their former life. However, the definitions tend to interpret

estore in terms of individuals adapting to changed circumstances and

learning new skills rather than returning to their former life roles. Pryor

2002 identifies rehabilitation as being the reconstruction of individuals

lives in the light of injury, illness or surgery. She sees rehabilitation as

being about lives that are lived in damaged or broken bodies.

ffectiveness Rehabilitation is described as promoting effectiveness or optimal func

tioning for the individual. Optimal functioning is implied as being func

tioning that can be achieved given any limitations the individualma y

have. Functioning could be interpreted in terms of emotional

an d

psychological functioning as well as physical functioning.

nabling and

facilitating Rehabilitation is generally described as being an enablingan d facilitat

ing process rather than a passive, doing for process. This is conducive

to rehabilitation being active rather than passive. In order for health

care professionals to take on this enabling an d facilitating role the

relationship between them an d the individual

ma y

need to be different.

An interesting question is: where does the power lie in this kind of

relationship?

Rehabilitation: The use of theories and models in practice, editor - Sally Davis , Elsevier, 2006


2/14

Learning and teaching

Autonomy

The International

Classification of

Functioning. Disability

and

Health

Chapter 1 Rehabilitation at a

Macro and

Micro

Level

9

Learning an d teaching is implied within some definitions, in terms of

rehabilitation being described as an educational process

that

enables

patients an d carers to learn ne w skills. Wade (1990) describes it as an

educational, problem-solving process aimed at reducing disability an d

handicap. This is using the old International Classification of Impair

ments, Disability

an d

Handicap

(ICIDH; World

Health

Organization

1980) terminology. Applying the International Classification of Func

tioning, Disability an d Health (ICF; World Health Organization 2001),

this could be interpreted as increasing an individual s activity an d

participation.

Autonomy is implied in some of the definitions, in terms of enabling

individuals to achieve goals that are important to them. However it is

only the Kings Fund definition (Sinclair Dickinson 1998) that stresses

that rehabilitation

should

be a process aimed at restoring personal auton

omy in those aspects of daily living considered most relevant by indi

viduals

an d

their family carers. This idea of restoring personal autonomy

fits in well with goal planning an d the concepts of empowerment and

advocacy. Taking autonomy one step further, Cardol et al

2002

suggest

that autonomy should be the ultimate aim of rehabilitation. In order for

this to happen, health-care professionals will need to explore the con

cepts associated with autonomy - e.g. power, empowerment - an d their

implications.

Rehabilitation can be considered in terms of the ICF (World Health

Organization 2001)

under

the classifications of impairment, activity an d

participation. Rehabilitation goals will be different related to each level.

Using the ICF as a framework for rehabilitation ensures that the focus of

rehabilitation is not only on the level of impai rment

an d

disability.

It

needs to focus on the individual s participation in the environment an d

in society. The goals at each level of the ICF will generally relate to each

other. For example for an individual

wh o

has

ha d

a stroke the goals at

each level might be as listed in Table 1.1.

The goals identified at the level of participation ma y be dependent

on the achievement of goals at the levels of impairment an d activity.

The ICF in relation to rehabilitation is discussed in more detail in

Chapter

2.

Table

1.1 Relationship

of

ICF categories

to

goals

ICF

Category

Impairment

Activity

Participation

Goal

To

I C gain

function

in hemiplegic arm and to prevent

complicatitlns

To

be

independent in

washing

and dressing

To be

able

to

return

to

work


3/14

Section REH ILIT TION

ND

THE

ICF

hilosophy

Stages of reh bilit tion

Stage

Stage

As well as a process, rehabilitation can also be considered as being a phi

losophy of care.tis about the wa y professionals think about individuals

and where they see their role in the process. As a philosophy, rehabilita

tion is about enabling, facilitating, empowering. Adopting this philoso

ph y of rehabilitation means that health-care professionals:

Value the patient as an individual, identifying their strengths

an d

weaknesses; their past achievements; their hopes for their future. This

is vital if professionals are to deliver client-centred care. Using assess

ment tools that assess individual s strengths, weaknesses, etc. can help

to promote this value.

Adopt strategies that facilitate an d

enable the individual to achieve

their full potential.

t

is important that there is some continuity in the

strategies used by rehabilitation professionals and that there is agree

ment as to

what

constitutes facilitating

an d

enabling strategies.

Realise that, although it may be necessary to devote more time to

enabling individuals to achieve their full potential, this will be cost

effective in the long term.

t

can be difficult to take this view, particularly

in an environment where rehabilitation is not seen as a priority. The time

involved is perhaps the most common factor identified by health-care

professionals in acute settings as a barrier to rehabilitation. However,

health-care professionals need to consider whether

this

is a valid argu

ment when set against the consequences of not promoting rehabilitation,

both for the individual and for health-care resources. Not promoting

rehabilitation in the acute setting may mean, for example, that the indi

vidual will not achieve their full potential given their limitationsan dwill

therefore need more resources an d support after being discharged.

Should be thinking about how the individual an d their family will

manage in the future, even though the extent to which they are able to

affect the individual s level of participationma y be limited. The focus

should be on individuals future quality of life as they see it.

One of the remaining difficulties is that rehabilitation can be seen as

something that happens in a specialised unit or

ward

whereas in reality

it needs to commence the moment an individual enters the health-care

system. This may be at the first contact with the GP or as an emergency

case in Accident Emergency.

t

can be helpful to consider this contin

uu m of rehabilitation as having four stages. The aims of rehabilitation

are different at each stage.

This is the initial critical stage when the individual is unconscious. The

goal of rehabilitation at this stage is to preserve life. Interventions at this

stage include:

Preventing complications

Providing verbal an d tactile stimulation

Supporting relatives.

At this stage the individual has recovered consciousness, is fully respon

sive and is beginning to regain some physical function. The goal of


4/14

Stage

Stage 4

Rehabilitation and

disability

Chapter 1 Rehabilitation at a Macro and

Micro Level

rehabilitation depends on the individual s needs. tmay be to maintain

a safe, comfortable environment, which may be an appropriate goal for

an individual with a

head

injury

wh o

is agitated, or it may relate to the

individual s functional

an d

cognitive ability. Interventions may include:

Managing challenging behaviour

Assessing the individual s functional and cognitive ability

Establishing everyday activities, e.g. eating at a table, using the toilet

rather than a commode

Giving the individual choices, e.g. about diet, clothes

Establishing alternative forms of communication

Supporting

an d

involving relatives.

A more active programme of rehabilitation is required at this stage,

which may take place in a rehabilitation

ward

or centre. The goals of

rehabilitation should be focused on the level of participation - being con

cerned with the individual s quality of life. This will involve:

Facilitating and enabling individuals to achieve their maximum

potential in washing, dressing, feeding, communication

an d

mobility

Ensuring that there is continuity of therapy programmes between the

different professional groups within the team

Empowering individuals by giving them informed choice

an d

by

involving them in the setting of rehabilitation goals

Providing psychological support to the individual

an d

their family

Providing a supportive, structured environment for the individual

and family.

The individual will have reached their full potential at this stage. The focus

will now be on enabling them to live with the disabilities they have and

maintaining their quality of life in relation to work, hobbies and social life.

At this stage they will either be at home or in an alternative setting, e.g.

a nursing home. They may attend a young disabled unit for respite care or

other day facilities, where the role of the team is to help them maintain

their quality of life. order for individuals tomaintain their full potential,

they may need follow-up appointments with the rehabilitation team,

which may result in further assessments and interventions.

Looking at rehabilitation in terms of four stages highlights the need for

rehabilitation to be a team activity. The goals of rehabilitation at each

stage will depend on the individual s impairments

an d the resulting dis

ability or the limitations that the impairment places on their activities.

Becauseof the effectthe individual s disabilities can have on the rehabili

tation process and outcomes it is useful to consider the relationship

between rehabilitation

an d

disability. Baker et al

1997

facilitated a survey

of education needs of health

an d

social-services professionals that

explored the views of professional

an d

client groups on the meaning of

rehabilitation and disability. As a result of the survey disability was iden

tified as being a dramatic lifechange for the individual, with rehabilitation

being an enabling process in which a range of groups in society worked to


5/14

2 Section

REH ILIT TION

ND

THE

ICF

meet the needs of the disabled person. This life change includes the way

in which individuals see themselves and others. The report emphasised

that disability should be related to the individual person with a disability

rather than the disabled . The use of language is an important considera

tion.The term the disabled is still used in the media and in literature. This

kind of language can be seen as discriminatory, as it implies that disabled

people are not seen as individuals

bu t

are defined by their disability.

There are views in the literature on the relevance of rehabilitation to

people who are disabled. Some of these views highlight the inadequacies

of the World Health Organization 1980 ICIDH framework, which did

not

take into account the societal factors that disable individuals. The ICF

(WorldHealthOrganization 2001)has rectified this by including the idea

of level of participation, which identifies environment an d societal fac

tors. This enables disabilities to be described from the perspective of an

individual s life circumstances an d the impact these have on their expe

rience (Bornman 2004).The focus on environmental

an d

social factors fits

in with Pryor s

2002

description of the creation of a rehabilitative

milieu , by which she means an environment that enhances the process

an d outcome of rehabilitation. To enable this environment to be created,

thought has to be given to the participants, the activities

an d

the setting

in which they take place (Pryor 2002).

t is interesting to consider whether definitions of rehabilitation

reflect the cultures of different countries. For example, in some countries

rehabilitation ma y be seen as synonymous with physiotherapy. In my

experience, some professionals an d individuals in the UK also hold this

view. The goal of promoting autonomy an d independence may no t be

congruent with the beliefs of individuals from different cultures. For

example, a

study

undertaken by Stopes-Roe Cochrane (1989,cited in

Holland Hogg 2001) comparing Asian people s attitudes to family

values with those of whi te people in the UK found tha t Asian people

valued conformity an d self-direction less than the people in the UK.

This

ma y not

be congruent with the concepts of autonomy an d inde

pendence. tis therefore essential that rehabilitation is focused on the

individual s needs an d goals an d that their values an d beliefs are taken

into account.

t

cannot be assumed that all individuals or professionals

have the same views about rehabilitation. In order for professionals to

deliver culturally competent rehabilitation care (Patrinos White 2001)

they need to:

Beaware of their ow n attitudes towards diversity and examine these

attitudes

Besensitive to

an d

respect differences

Be knowledgeable about different cultures to enable them to

interpret behaviours appropriately

Have cultural skills that enable them to respect an d value culture - this

may include the use of appropriate touch and non-touch when

communicating and respecting the individual s need for physical space

Be able to communicate cross-culturally, which may mean the

involvement of interpreters or people in the community.


6/14

Chapter

1 Rehabilitation at a

Macro

and Micro level

3

Focusing on what is important to the individual an d what their goals are

transcends all cultures.

TE MWORK

Rehabilitation, because of its complex nature, cannot be achieved by one

professional group alone. Rehabilitation has become synonymous with

teamwork. A review of the literature on trends in rehabilitation policy

(Nocon Baldwin 1998) highlighted the need for rehabilitation to be

centred on the most important aspects of an individual s life with the

involvement of service users. To enable this to be achieved rehabilitation

needs to involve a group of professionals all working with the same pur

pose of meeting the individual s goals. This process must involve the

individual and their family. The Kings Fund definition of rehabilitation:

a process aiming to restore personal autonomy in those aspects of daily

living considered most relevant by patients or service users, an d their

family carers (Sinclair Dickinson

1998/

p.1)) also highlights the need

for a multiprofessional approach to rehabilitation. This definition also

focuses on individual-centred care, emphasisingwhat service users

an d

their carers, not the professionals, see as important.

The five main principles of individual-centred care can be identified

as being empowerment of individuals, enhancement of staff, multidisci

plinary integrated pathways, multidisciplinary teamwork an d restruc

turing

an d

decentralisation of services (Hutchings et a12003).One could

argue that truly individual-centred care requires interdisciplinary team

work in which there is not only a shared philosophy an d collaboration

bu t also blurring of professional roles in order to meet the individual s

goals. This use of terminology brings into question the different terms

used when talking about rehabilitation. Terms such as multiprofessional,

interprofessional, transprofessional, multidisciplinary, interdisciplinary

an d transdisciplinary are often used interchangeably. What is the differ

ence between professional

an d

disciplinary? Between multi-

an d

inter-?

Table 1.2 gives some dictionary definitions.

Multi- implies that there are a number of different professional

groups working together, whereas inter- implies that there are a number

Table

1.2 Definitions of

team

types

Term

Professiona

I

Disciplinary

Multi-

Inter-

Definitions of

Team

Types

xford

Paperback

Dictionary 998

Someone who belongs

to a

profession which

isan

occupation

that involves knowledge and trainig at

an

advanced level of

learning

Oforfor a

discipline which

is described as

training

that

produces

a

particular

skill;or a

branch

of

learning

or instruction

Involving

many

Between

or among


7/14

4 Section 1 REHABILITATION

AND

THE ICF

of different professionals working together towards a common purpose

and that there is some blurring of boundaries. Professional can be taken

to mean the different professional groups whereas disciplinary can be

taken to refer to the knowledge and skills underlying different profes

sional roles. This is supported by Payne

2000 ,

who distinguishes

between professional

an d

disciplinary by suggesting that professional

is concerned with the functions

an d

activities associated with the differ

en t professional groups, whereas disciplinary is concerned with the

knowledge and skills required for different professional roles.

Norrefalk 2003 takes on the challenge of trying to make sense of the

different terminology an d identifies that:

Amultidisciplinary team

Involves the efforts of individuals from a number of disciplines

Is used to describe a team consisting of many different professions

working in rehabilitation

In an interdisciplinary team

Members

no t

only require the skills of their own disciplines

bu t

also have the added responsibility of the group effort on behalf of

the activity or individual involved

The skills necessary for group interaction are required, an d the

knowledge of how to transfer integrated group activities into

a result that is greater than the simple su m of the activities of each

individual discipline

The group activity is synergistic

In a transdisciplinary team

Allborders are broken between the individual professionals.One

member of the team acts as a primary therapist, being supported by

the rest of the team. This primary therapist may be a health-eare

assistant with specific rehabilitation training (jackson

Davies 1995 .

The terms discipline an dprofessional can be identified as having more

or less the same meaning. Norrefalk 2003 makes the point that it is

important that rehabilitation professionals nationally

an d

internationally

use the same terminology with the same meaning. He makes the sugges

tion that multiprofessional team is used rather than multidisciplinary

team . As the team consists of different professionals, this does perhaps

make sense. However, there can still be seen to be a difference between

multi-

an d

inter- , with the interprofessional team truly working across

boundaries in order to meet the goals that are important to the individual

an d have been identified by them. This fits in with the view of McGrath

Davis 1992 , who consider the distinction between multidisciplinary

an d

interdisciplinary to be their focus, with multidisciplinary being

focused on the level of activity an dinterdisciplinary focused on the level

of participation.

t

is the level of participation that enables goals to be

more realistic for the individual. In rehabilitation, professionals should be

working towards goals that are important to the individual.

Collaboration

Collaboration is the key to effective team working an d can be described

as the process of working towards a common goal with shared planning


8/14

Figure 1.1 Concepts related

to collaboration


Micro

level 5

an d action. The team has joint responsibility for the outcome (Lindeke

Block 1998 . Interdisciplinary collaborative care differs from multidisci

plinary collaborative care in that it involves joint decision making,

shared responsibility an d shared authority (Lindeke Block1998).Pro

fessionals work together an d cooperatively to achieve an agreed indi

vidual-centred goal. Transdisciplinary care takes this way of working

one step further in that there is a complete blurring of goals with one per

son being responsible for ensuring that the individual s needs are met

(Hutchings et al

2003 .

Although collaboration is the ultimate aim in

practice it is not always easy to achieve. Freeman et al 2000 , as a result

of looking at case studies of six teams, identified that difficulties in devel

oping collaborative practice can be identified at the levels of the organi

sation, the group an d the individual. There are a number of concepts that

affect all these levels, which need to be taken into account for collabora

tion to occur. Figure 1.1 identifies concepts related to collaboration,

which are the basis for a taughtmodule on collaboration at the School of

Health

an d

Social Care, Oxford Brookes University.

Although team working is seen as being central to rehabilitation there

is little published evidence for its effectiveness (Embling 1995,Waters

Luker 1996,Proctor-Childs et aI1998). There is evidence at a clinical level

from professionals who have changed from one approach to another that

it does have an effect on individuals (McGrath Davis 1992). Using

a case study approach, Proctor-Childs et al 1998 explored the realities of

multi-

an d

interdisciplinary teamwork. Although this was a small study

using only two case studies, both from a neurorehabilitation setting, the

findings support the work of McGrath Davis

1992 .

Proctor-Childs


9/14

6

Section

REH ILIT TION ND THE

ICF

et al 1998 identified the following six outcomes that have the potential

to enhance an individual s progress:

Continuity Professionals learned skills an d knowledge from each

other, which they then carried over into their ow n practice

Consistency

Achieved because professionals identified how other

team members interpreted events - this resulted in them being able

to pick up

on individuals views an d act in a similarwa y to

colleagues

Reduction ofambiguity The same messages were given to individuals

an d

their families because of joint working, joint discussion

an d

joint

evaluation

ppropriate

referrals

Professionals ha d a greater knowledge of each

other s roles so were able to refer appropriately to other members of

the team

Holistic

information A holistic picture of the individual was achieved

because of joint working - because of the perspectives of a number of

team members, decisions were made from a wider knowledge base

Problem

solving

As discussion wa s focused around specific aspects of

individual care joint strategies were developed and appropriate

decisions made.

In order to achieve the above outcomes the team needs to be a close

working team, comfortable with each other, motivated by the same phi

losophy. Using the social identity approach to team building identified

by Hayes 2002

could help achieve this. This approach has three main

aims:

Tomotivate the team by creating a sense of unity an d belonging.

This then enables them to cooperate together to achieve team goals,

which would need to be aimed at patients goals

Strategies Ensure the team is well defined and t hat there is cooperation

with others in the organisation; define the team s resources clearly;

set mutually agreed boundaries for the team

Tocreate a climate of

mutual

understanding to enable team members

to be aware of each other s contribution an d to see how individual

skills, abilities and tasks contribute to the team as a whole

Strategies Establish clear lines of communication

an d

different

strategies for communication; be clear

what

the team s aims an d

objectives are; identify opportunities for informal communication,

e.g. social activities

Toenable teammembers to feel proud of belonging to their team

an d

to recognise their contribution to the organisation

Strategies

Appraise each other s successes to each otheran d to the

larger organisation; recognise each other s skills an d abilities;

provide training opportunities for individuals an d for the whole

team; have official recognition from the wider organisation, which

could be in the form of rewards.

The implications of this approach to teams is that team buildingmust be

a priority and must address:


10/14


Micro Level

7

Attitudes values andbeliefs Team members exploring these in relation

to rehabilitation and to team working

Trust

and

respect Setting ground rules within teams

Role

Team members having the opportunity to explore their

understanding of each other s roles

Contributions

Team members need to see

ho w

their contribution

affects

not

only the team bu t also the wider strategic picture.

Using such an approach to team building could help rehabilitation teams

truly achieve interdisciplinary working.

QU LITY OF LIFE

The ultimate aim of rehabilitation

ca n

be identified as maximising an

individual s quality of life. That is, the quality of life

that

is important

to the individual,

not w hat

professionals think it

should

be. Quality of

life is a difficult concept to define as it is personal to the individual.

What is important to on e person will no t have the

same

importance for

another person. In conducting a concept of analysis of quality of life,

Meeburg (1993) concluded that quality of life is an overall satisfaction

with life as determined by the individual

whose

quality of life is being

evaluated. Meeburg (1993) gives the example of a person living in

poverty

wh o

may be happy with their life as they

have known

nothing

else. However, a person outside those conditions

would

evaluate that

person s life as less than ideal. This example, however,

doesn t

take into

account people whose quality of life

has

changed as a result of circum

stances beyond their control, e.g. illness, trauma, bereavement, financial

difficulties.

To unders tand the complexity of the concept of quality of life it is

helpful to consider its attributes or characteristics as identified by the

concept analysis conducted by McDaniel

Bach

1994 .

Dynamic nature Quality of life may change at various stages or ages in

an individual s life. Itmay alsochange from day to day.This is important

to consider in terms of rehabilitation, as an individual s quality of life

may be affected by a number of factors including the rehabilitation

process itself, lack of resources

an d

the process of adaptation. These

effectsmay be short- or long-term.

Multiple

dimensions

Quality of life is made

up

of a

number

of

dimensions, for example physical functioning, social interaction, family

and friends. The importance these dimensions have for individuals will

be different. This means that it is vital that the team identifies what is

important to the individual and

what

they see as a priority in terms of

the different dimensions of their quality of life.

Interaction

The interaction

between

the

individual

an d their

environment

ma y

influence their quality of life. Environment can be

thought of as the rehabilitation environment, the home environment

an d

the community environment. Attitudes can also be considered as

part of the environment.


11/14

8 Section

1

REHABILITATION

AND THE ICF

Congruence

Quality of life is affected by the difference between an

individual s hopes an d expectations an d their actual life. This can be

a major influence on the quality of life of people with chronic illness

and or a disability, an d is a factor that needs to be considered by

rehabilitation professionals.

These characteristics identify quality of life as more than an overall sat

isfaction with life. McDaniel Bach s

1994

content analysis identified

quality of life as a dynamic, unique process that is influenced by the

dimensions of an individual s life. It is the product of the congruence or

lack of congruence between the individual s hopes

an d

expectations and

their actual life conditions. It is interesting to consider whether different

populations see quality of life in a different way. Lau et al (2003), in

a study defining quality of life for elderly Chinese people who h ad h ad

a stroke, identified that there were similarities

an d

differences in the

qualify of life components identified in the study. The study identified 36

components, which can be classified using the ICF categories (Table 1.3).

Some components can be listed

under

more than one category.

Toobtain these components the following questions were asked in the

study:

What does it mean for you to have a good life?

What are your reasons for saying so?

Apart from [what was said], what other aspects do you feel are

important for you to have a good life?

How would you rate your own life?What are your reasons for

saying that your life is [very poor, poor, fair, good, very

good/excellent]? (Lau et al2003, p. 711)

Table

1.3 ICF

categories

and

components

of qualityof life

Body Function

and

Structures

Limb function

Bowel

and

bladder

function

Vision

and

hearing

Language ability

Cognition

Pain

and

discomfort

Energy and fatigue

Sleep and rest

Activities and Participation

Activity participation

Activities of daily living

Dependence on

medication/treatment

Personal

relationships

Sexuality

Informal

social

support

Opportunities

for new

information

and

skills

Sense

of

acceptance

Environmental

Factors

Working

capacity

Formal

social

support

Social

integration

Physical

safety

andsecurity

Housing

Finance

Transport

Physical environment

Leisure

Personal

Factors

Happiness

Dependence on

medication/treatment

Self-concept:

body

image

Self-concept:

self-worth

Coping

Spirituality

Life

satisfaction

Sense

of control

Negative feelings

Source: With

permission

from Lau et al 2003


12/14

Figure

1.2 Categorisation

of

roles

Chapter

1 Rehabilitation at a

Macro

and Micro

Level 9

Toassess what quality of lifemeans for individuals, health-care profession

als could use these questions more generally.In terms of the differences in

quality of lifefor Chinese and Western populations, Lau et al2003 identi

fied that the main differences were in the areas of eating/appetite , being

accepted/respected and family , which Lau et al 2003 felt were du e to

sociocultural factors.

Identifying quality of life as incongruence between the hopes and

expectations of individuals and their actual life conditions highlights the

need for rehabilitation health-care professionals to work with individuals

to narrow the gap between what theywant

and w hat

is actually possible.

One

wa y

of doing this is to consider quality of life as being made up

of the roles we as individuals have in life.

t

is these roles that make up

our quality of life. Role theory can be used to explain the roles individu

als assume during various situations (Chin 1998).t is these roles that

govern an individual s behaviour in a group

an d

determine their rela

tionships with other groupmembers. The roles that individuals have can

be categorised as primary, secondary

an d

tertiary (see Fig. 1.2).

Focusing on what is most relevant to the individual means that reha

bilitation has to be concerned with that individual s quality of life.tis

necessary for the team to establishwhat is required to enable individu

als to return to their former roles in life or to establish new ones in order

to achieve an acceptable quality of life. One way of doing this is to enable

the identification of life goals. In a literature review of 39 articles on life

goals and their influence on the rehabilitation process, Sivaraman Nair

2003 concluded that:

Individuals strive either to attain or to avoid life goals

The participation in the rehabilitation programme maybe influenced

by life goals

t

is not clear whether rehabilitation outcomes are improved by the

focus on life goals.

Although there is a need for further studies into the effect of life goals on

the rehabilitation process, life goals is one

wa y

of ensuring that the


13/14

Section

1

REHABILITATION

AND THE ICF

rehabilitation programme is focused on what is important to the indi

vidual an d their quality of life.

One concept to consider in terms of control is autonomy, which

implies a sense of control an d can be seen as central to quality of life.

However, the choices they have an d the resources available can limit

autonomy for individuals. This may highlight ethical issues, for example

the ethics of rehabilitation professionals enabling

an d

encouraging indi

viduals to take control an d be autonomous when the resources required

for them to do so, in terms of facilities, equipmentan d financial support,

are not available. tmay then be that professionals are setting individu

als up to fail. A

wa y

of avoiding this is for rehabilitation professionals

an d individuals to negotiate control

an d

support, which would then

acknowledge the disempowered state ofboth individuals an d rehabilita

tion providers (Clapton Kendall 2002).

Wellness is an interesting concept to consider in relation to quality of

life. Wellness can be identified as a dynamic process that integrates

physical an d psychosocial development, spirituality an d the environ

ment (Drayton Hargrove Derstine 2001). Wellness can be achieved

without physical independence. Perhaps quality of life is about achiev

ing a level of wellness that is appropriate for the individual an d that is

identified by the individual. Putnam et al

2003

conducted a study to

explore how people living with long-term disabilities defined health and

wellness. The 99 adults in the study ha d a variety of disabilities includ

ing polio, cerebral palsy, multiple sclerosis, amputation an d spinal cord

injury. Focus groups were used to explore health promotion practices,

barriers an d opportunities to being healthy an d well. The participants

defined health an d wellness as being independent or self-determining;

being able to do what they wanted to do; having an emotional an d phys

ical state ofwell being; an d being free from pain. The results highlighted

the fact that the state of being healthy an d well is not solely dependent

on the individual bu t is associated with the cultural, social an d physical

environment.

CONCLUSION

With the

introduction

of the NHS

plan

and the National

Service

Frame

works the

amount

of rehabilitation w ork being carried out within the

National

Health Service has increased the focus being on an integrated

approach involving rehabilitation and social services.

Rehabilitation is a

complex

process which needs to

actively

involve the

individual

their

family and

the

team and commence

at theacute

stage.

The

focus

of

rehabilitation needs

to be on

health

wellness and qualityof life. In

terms of quality of life rehabilitation needs to focus ongoals that are impor

tant to the individual. However the

concepts

of autonomy and control need

to

be

taken into account. It isalso important that health-care professionals

consider

rehabilitation

as a philosophy of

care

as well as a

process.


14/14


Micro

level

2

Teamwork is

essential

to rehabilitation; the team

must

work

collaboratively

with the individual

towards

the

individual s

goals. It is

essential

that

reha

bilitation

professionals value

and take into

account

the needs of individu

als and understand their beliefs and

values.

More

research

is needed into

the

effectiveness

of interdisciplinary

and

multidisciplinary

teamwork

on

rehabilitation.

QUESTIONS FOR

DISCUSSION

How do you ensure that rehabilitation is focused on the individual s

quality of life?

As a team, how do you see rehabilitation? Is it a process? A

philosophy? When does it begin?

How do others in your hospital or Trust see rehabilitation? Is there

a consistency in their views?

Do any aspects of the social identity approach apply to you as

a team?

References

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Bornman J

2004

The world health organisation s

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1998

Theoreticalbases for rehabilitation.

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Derstine JB,Drayton Hargrove S (eds)

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rehabilitation and team work

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