83
The CR Workforce
What competencies are currently evident in the workforce in CR in Qld?
What are the barriers to utilising current competencies in CR?
What are the potential solutions to these barriers?
This part of the report outlines several important analyses of the data that comment on the status of CR
competencies in the Queensland Allied Health, Nursing and support personnel workforce.
UThe section describes the analysis of the understanding of CR that underlies current practice. This analysis is
n derived from the Interview data with practitioners, who responded to several questions about the definition of
d CR and its purpose. Practitioners also provided both successful and challenging examples of their practice in
e CR, from which it was possible to examine the translation of definitions into practice.
r
s The section also presents the results of the Queensland–wide survey of competencies. In the survey,
t practitioners were asked to indicate the extent to which they possessed each competency domain and how
a important it was to their CR practice. This data provides important comment on practitioners’ current level of
n understanding and confidence of their knowledge, skills or abilities and attitudes.
d
i The final section contains an analysis of Interview data pertaining to the issues and challenges that prevented
n practitioners from implementing the competencies associated with CR. Barriers were identified by practitioners
g in relation to their daily practice, but they were encouraged to think about innovative solutions for these
barriers and consider any reasons why such barriers might not emerge for other practitioners. Therefore, this
o analysis also contains some suggestions and solutions that were contained in the data.
f
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
83
Understanding of CR by Practitioners
Few participants provided a comprehensive definition of CR about which they appear to have deliberated prior
to this Interview. Most participants began their discussion of CR and its purpose with expressions that indicated
the difficulty associated with this question (“Oh gee, let me think…”, “Um, I don’t know, let’s see…” and so
forth). The most common description of CR involved a process of eliminating its ‘non-features’. For instance,
many participants described CR by referring to “acute” or “traditional” rehabilitation, indicating the prominence
of this acute model (e.g., “Whereas traditional definitions of rehabilitation are about regaining function, in the
community context it is more about community integration goals”).
For most participants, their understanding of CR was based on a critical connection to hospital rehabilitation.
CR was generally defined as something that occurred later in the recovery process, when acute rehabilitation
was no longer necessary or useful. Four common and pervasive themes emerged from the data to reflect
typical beliefs about CR and its primary purpose. These themes clearly identify the model of CR that currently
dominates Queensland practice, namely, a useful strategy to promote improved and more sustainable
outcomes for rehabilitation by reducing demand on the health system, preventing unnecessary hospitalization,
reducing length of stay and easing the transition back to the community.
The importance of Consumers’ home environments was stressed repeatedly by participants, but usually from
the perspective that rehabilitation and therapeutic interventions were more likely to have a sustainable result in
that context. Although it was generally agreed that CR occurred in the home environment, there was
considerable debate on this topic and many examples of centre-based practice were cited despite the rhetoric
of community-based models. For instance, a number of practitioners indicated that they believed Consumers
were “more motivated when they have to make the effort to come to the centre”. The majority of practitioners
indicated that they preferred to operate in the community context, but expressed significant difficulties that
prevented them from doing so and, in many cases, forced them to deliver services in a centre or an acute
setting. An interesting irony was the fact that participants located in several new CR services described their
intention to work more in the home in future, but also commented that their workload prevented home-based
service delivery.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
84
A majority of the participants also agreed that CR was more likely than acute rehabilitation to be focused on
Consumer-driven goals. However, the discussion of Consumer goals was often superficial in that the main
reason for focusing on these goals was to increase commitment to the therapeutic agenda. Few participants
expressed full recognition of the important message contained in Consumer-focused practice. There was
considerable discussion in many Interviews about how Consumer goals could be modified to ensure that they
were “realistic” and “achievable”. Realistic and achievable tended to mean “able to be accomplished by the
therapist in a short timeframe”.
Theme
CR is focused on
Consumer goals
CR is based in the
consumer’s home
CR as a strategy to
prevent or shorten
hospitalisation
CR as a transition
strategy
Some Examples of Data to Illustrate Themes
Driven by what is important to patients, realistic goals that Consumer wants to achieve, life
focused goals they choose as opposed to discharge focused goals, helping Consumers to
achieve their goals, achievable goals that would improve quality of life, focus on what
Consumers enjoy in their lifestyle and environment, helping Consumer to set and reach their
goals, facilitate Consumers - give direction if asked, help Consumer identify and achieve
goals, CR practitioners are tools to help Consumers achieve outcomes, learning to live life as
best they can.
Based in person’s home, maintain people in their own home, in the home environment, in
people’s home environment, understand their home and what they are trying to achieve in
their home, keeping people at home, brief visits in the home, keep person in their own home,
rehabilitation in the home or a local facility, home visits allowing them to be in their own home
because this improves transfer of learning, it is easier to get outcomes in their own home.
Promoting early discharge from hospital, preventing or shortening hospitalization, avoid
hospital by keeping people safe at home, prevent deterioration, prevent risks and keep
people healthier, sustain daily life in own community, risk identification and education, focus
on remaining in the community, keep people fit in the community.
Easing the transition from hospital to home, transition services to move people back to the
community, post-acute rehabilitation, most CR is conducted with Consumers who are
recently discharged, but always occurs after hospital rehabilitation.
Four minor themes were also present in the Interviews, but were reflected by fewer participants and in less
consistent ways. The first of these themes focused on the intent of CR, namely to promote independence – this
theme highlighted the difference between acute therapy and CR that derived from their focus on functional
outcomes rather than impairments. A related theme expressed by a few practitioners was based on the fact that
CR focuses on the entire context of the Consumer and all their needs rather than a single impairment as it was
presented in a clinic setting. CR assessment was considered to be holistic, giving attention to the entire person,
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
85
their family, their home environment, their community and all their needs. Practitioners acknowledged that this
type of practice in the community could not occur without collaborative teamwork that brought together a
number of practitioners with complementary skills and adequate knowledge of local resources that could
address the needs of Consumers.
Theme
CR facilitates
independence of
Consumers
CR gives attention
to the whole
person
CR involves
teamwork with
other practitioners
CR requires
knowledge of
resources
Some Examples of Data to Illustrate Themes
Facilitate independence, maintain the independent functioning of the person, a functional
focus rather than an impairment focus, focus on getting Consumer back to activities
Holistic assessment, acute care doesn’t look at the whole patient in their context, whereas
CR looks at the bigger picture
Based on a team work approach, a multi-disciplinary team, joint visits with other team
members
Knowledge of resources, using the resources that are available in the community
In describing CR, a majority of practitioners deliberated about the fact that CR required them to balance the
demands of being a “generalist” or a “specialist”. In using the term specialist, they were referring to their
discipline-specific practice, although a few practitioners believed that CR was their specialist area. In contrast to
this view, the majority of practitioners considered their CR role to be a “jack of all trades”. Some participants
stated that the “pace of CR was too slow” and that it was not sufficiently stimulating. A few participants
described the fact that the community offered an easier alternative to the intensity of hospital-based clinics or
private practice. Many commented that it was necessary to complete hospital training prior to working in the
community to ensure adequate knowledge of disease/injury and treatment processes. Similarly, practitioners
reported being concerned about losing their discipline-specific skills if they focused too heavily on community
practice.
Overall, comments by practitioners indicated a perception of an inferior status of CR in comparison to discipline
specific therapy. Practitioners indicated that acute rehabilitation often took priority over CR. They reported being
more able to document the benefits and outcomes of acute rehabilitation than CR, even though many believed
that the most sustainable outcomes for Consumers were associated with CR. Funding was also more likely to
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
86
be directed to acute services than to community services. For many participants, the practice of CR remained
identical to their discipline-specific practice, although the location may have been Consumers’ homes.
There are many forms of CR, all of which perform an important function, and tend to fall on a continuum defined
by the location of service delivery. The different locations of rehabilitation (e.g., acute hospital, intensive
inpatient, intermediate facilities and community) are most aptly described in the UK Audit Commission Report
(2000) through their review of the rehabilitation continuum for elderly citizens, as shown in the figure below.
Within the community sector, services can also include a range of settings, such as day hospital (i.e., outpatient
appointments at a hospital), transition services, home therapy packages and finally, services that are firmly
based in the community.
Figure 5: Illustration of the Rehabilitation Continuum from UK Audit Commission Report (2000)
In the current study, it was apparent that the dominant CR model focuses on the movement of individuals from
acute care settings to home-based care, the prevention of return to acute settings and the delivery of
therapeutic interventions in the home. Although this type of model is useful and necessary, Consumers, experts
and some practitioners indicated that it would be desirable for CR in Queensland to shift further along the
continuum towards fully community-based models. The importance of retaining cooperation and communication
between the different locations of rehabilitation was critical to most practitioners as this ensured continuity of
service provision for Consumers.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
87
Another continuum of significance in this study concerned the dimension of Consumer control. Even CR
models, which are based firmly in the community, can differ according to the degree of control that is afforded
to Consumers. Although many models have been described, CR services can generally be classified according
to one of four models, namely the expert model, the transplant model, a partnership model and models based
on self-determination by Consumers. The key elements of each of these models are shown below:
The Expert Model (Cunningham & Davis, 1985) is often associated with rehabilitation in institutional settings
and has the following dimensions:
x Practitioners are experts, have knowledge and skills and aim to promote Consumer’s functional status
x Consumers are often passive recipients of a service who comply with treatment and advice
x De-skills Consumers and family by creating dependency, feelings of inadequacy and reduced efficacy
x Unique knowledge and skills of Consumers and family is ignored
The Transplant Model (Mittler & McConachie, 1986) has the following dimensions:
x Trains and educates Consumers and family in skills/knowledge necessary to promote functional status
x Consumers and family are regarded as resources for expanding the coverage of the service
x Family members become co-educators or co-therapists, but the professional remains the instructor
x Sustainable transfer of skills with a two-way dialogue
x Practitioners are still in control
The Partnership/Negotiating Model (Cunningham & Davis, 1985) has the following dimensions:
x Recognises the expertise and ultimate knowledge of Consumers and family
x Recognises diverse needs of different families
x Active participation of Consumers and family in decision making
x Professional supports the Consumers and family in making decisions
x Assumes Consumers, family and professional will reach agreement through negotiation
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
88
The Self-Determination Model (based on Developmental Disabilities Resource Centre, 2005) sits at the far
extreme of the continuum. For people with disabilities, this model is based on the principles of freedom (the
right to make choices), authority (the right to decide for oneself), support (the right to choose the people you
want to help you), responsibility (the need to do things the right way), and confirmation (the right to be heard
and recognition that it is your life). A self-determined model of CR would contain the following characteristics:
x All individuals are able to participate in goal-setting and decision-making to the degree they choose
x Individuals have access to the full choice of practitioners, services, locations, and methods of receiving
rehabilitation
x Where appropriate, family members or natural supports can provide services and be supported to do
this if necessary
x Individuals and their families are supported to engage in long-term planning for their well-being
x Individuals and their families are expected to be cost effective, but will not be penalised or limited on
economic grounds
x Systemically, there is a means to manage fluctuations in need and emergencies
x Self-determination is available to the extent possible and desired in all programs and Informed choice
is a central theme
x The roles and responsibilities of all parties are explained, acknowledged and formalized
x A system of “transparency” is developed where all parties have the same information and
understanding of the situation and the process - Individuals are supported in their understanding of the
system
x Community contribution is an integral component of the process
In discussing their CR practice, the language used by participants reflected a therapist-controlled expert model
of CR (e.g., “motivating people to get them to do what you want them to do”, “we put these people back in their
homes”). Although there were some elements of transplant and negotiation models, the discourse contained in
the Interviews was dominated by statements that reflected the capacity of the therapist to “make” things happen
to Consumers and the responsibility of practitioners to ensure that rehabilitation progressed in a socially
acceptable form (e.g., “make them [Consumers] safe in their own home”). There was also an implicit focus on
outcomes that were considered to be suitable to practitioners and goals that they wanted to achieve from the
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
89
rehabilitation process (e.g., “you [the therapist] look at the patient and you say, what do they need to be
successful, to stay at home”, “that’s not what we [therapists] want to achieve”, “we [therapists] have to find ways
of showing them [Consumers] what they should be doing”). Consumers were often discussed as components of
the rehabilitation process that “had to be managed” to prevent them from sabotaging the outcomes and making
the task more difficult for practitioners (e.g., “if we don’t empower people, you are always going to be tied to
them”, “they still expect to continue daily therapy when they leave hospital”, “they can be difficult – you have to
find ways of getting them to do it [therapy]”).
These themes were juxtaposed against the rhetoric of Consumer-driven services and empowerment, indicating
a significant gap between theory and practice for many participants. Discourse and philosophy is an important
component of CR as it creates a discursive framework that, in turn, determines reality (Cott, 2004). The
discourses that have dominated rehabilitation over the years are a reflection of the dominant perceptions about
the role of the person with a disability in the process. The discourse that dominated for many CR practitioners is
one that places the Consumer as a passive recipient of treatment, contributing to the development of goals, but
not in control of the process and, in some cases, impeding progress as a result of unrealistic goals or
unwillingness to implement recommended strategies. The discourse of Consumers with choice and control was
evident in only a few Interviews.
In the case of CR, it is particularly important that discourses of power and control are shifted to emphasise the
role of the Consumer. For many Consumers, they are beginning a life-long process of taking responsibility for
managing their own condition and making choices in their lives that are based on a new set of parameters. The
philosophies of Consumer empowerment and engagement are, therefore, central to this model. However, many
practitioners noted that the ability to sustain these frameworks within the health system was limited:
See you can create all these competencies but they’ll [practitioners] be working in a vacuum. They might
have a frame work or a philosophy to work within and know why they're working this way, but the danger is,
people fall back to what they know, and they know their therapy skills or their discipline-specific skills or
whatever. They’ll tend to dilute the CR component and retreat to what they're comfortable with.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
90
The Competencies in the Existing Queensland CR Workforce
The Queensland wide survey revealed vast differences in CR proficiency levels across the total sample. There
was a general trend for the rated importance of a competency to increase with increased beliefs about
proficiency in the competency (see Table 13). For instance, CR practitioners believed that they were most
proficient in Holistic Focus, Networks and Consumer Engagement. These areas were rated as being in the top
five most important competency domains. Frameworks of Understanding was considered the competency of
least proficiency and also of least importance. Although there was substantial variation among participants in
their ratings of this domain, this finding supports the notion that those who consider Frameworks for
Understanding as being less important, are likely to have less proficiency in this area, possibly indicating less
understanding of its relevance to CR practice. When considering time in CR practice and current skill level, the
survey results indicated that CR practitioners who had worked in CR greater than 10 years reported having
higher proficiency in Consumer Engagement (F(4,23)=3.03. p<.05), and Community Engagement
(F(2,23=2.86), p<.05), than those who had worked in CR for 1 – 2 years. These findings not only suggest that
experience in the CR role significantly impacts on competence in some skill areas, but that some time in CR is
necessary to develop insight into a lack of proficiency in these areas. Although not statistically significant,
Networks also tended to improve over years in practice.
Table 13: Overall Mean (SD) Scores for Competency Domains
Competency Domain
Important to CR
practice
Mean (SD)
Rank
I Have this
competency
Mean (SD)
Rank
1
Frameworks of Understanding
2.05 (.78)
10
2.28 (.88)
2
Networks
1.18 (.38)
4
1.45 (.60)
3
Cultural Awareness
1.56 (.64)
9
1.97 (.67)
4
Holistic Focus
1.13 (.41)
3
1.26 (.49)
5
Consumer Engagement
1.05 (.22)
1
1.46 (.60)
6
Service Continuity
1.55 (.83)
8
2.08 (.71)
7
Reflective Practice
1.10 (.38)
2
1.56 (.59)
8
Community Engagement
1.54 (.64)
7
2.00 (.79)
9
Boundaries and Personal Safety
1.25 (.43)
5
1.75 (.67)
10 Systems Advocacy
1.51 (.65)
6
2.14 (.82)
NOTE: Rating Scale for Importance: 1=Extremely, 2=Highly, 3=Somewhat, 4=Not at all; Rating scale
competency proficiency: 1=Very much, 2=Somewhat, 3=A little, 4=Not at all.
10
2
6
1
3
8
4
7
5
9
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
91
Barriers to Utilising Competencies
In the Interviews, practitioners were asked to describe their experiences with CR, and the factors that impacted
on their ability to deliver CR. In this data, a set of barriers was identified that appeared to interfere with the
implementation of competencies. These barriers included:
x Systemic Issues Associated With the Lack of Profile for CR
ƒInsufficient Organisational and Community Resources
ƒLack of Technological Skills and Resources
ƒLack of Structured Protocols and Documentation for CR
x Lack of Evidence Base for CR
x Workplace and Job Structures that Prevent Good Practice
x Lack of Flexibility and Confusion about Eligibility Criteria
x Lack of Recognition of a Specialised Role
x Vulnerability as a result of CR practice
x The Assumption of Knowledge
ƒNew Graduates
ƒComplacency and Maintaining the ‘Status Quo’
x The Perception that the Consumer is the Problem
x Lack of Person-Job Congruence
ƒLack of Interpersonal Skills, Self-reflection and Consumer-focus
ƒBeing a Team Player
ƒAdaptation to a CR Role
x Clinical-Focused Practice
x Contextual Barriers
x Lack of Pre-service Education and Preparation for CR
ƒLack of Community Awareness – ‘Culture Shock’
ƒLack of organizational and community resources
ƒEmotional and psychological issues
x Maintaining Clinical Competence
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
92
Systemic Issues and Lack of Profile for CR
Many participants felt that CR has a low profile, lacks leadership and “is not on the agenda”. Participants hoped
that this audit would remain visible and be used to enhance CR development and implementation. Most
participants felt there was a lack of understanding and structured guidelines from all levels of government,
organizations, sectors and communities, which has frustrated the development, implementation, evaluation,
and education of CR. These systemic barriers were viewed as artificial barriers, which participants felt were
“inelastic” and excluded the Consumer. Participants felt that this lack of clear conceptualisation, regulations
applying to service providers and territorial barriers made it difficult to implement the CR model.
Participants also felt that “everyone thinks they know what CR means” but in reality few people had a good
understanding of its principles. There was strong consensus among participants that there was a need to define
CR but also to change the “language [of CR] so they [other professionals and community] understand what it
is”. Participants reported that the language of CR can often “confuse people”, particularly those in the
community from different cultural backgrounds. Participants also reported incidents where community and
hospital staff “don’t know what each other does” and/or don’t have much “respect for each other”. They believed
that it was necessary to “consult with the right people who are really doing it - both nationally and
internationally”. Such networks would facilitate enhanced understanding of CR and develop networks among
“powerful people in policy and decision-making positions”. Some participants reported that the “community
sector voice lacks representation” at important influential gatherings about rehabilitation.
Lack of clear CR policy guidelines, sector and organisational interfacing and co-ordination, and poor
organisational structures resulted in participants experiencing a lack of communication, uniformity and
information sharing between all stakeholders. Most participants concluded that CR lacked a coordinated
approach and strong leadership with good knowledge of the principles of CR. Therefore, “bandaid” approaches
to CR were being used, resulting in “fragmented” services with duplication in some areas and gaps in others.
…they seem to be setting up [the CR teams] quite differently, some of them have got different outcome
measures…why are these decisions being made?…what are you basing these decisions on?…why [is]
another team…doing something completely different?…And is that a good thing? And is the Government
happy with that?…it concerns me a little bit.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
93
CR teams were often established without CR-specific training to aid in their professional development or guide
their understanding of the program they were implementing. Participants commonly reported the feeling that
“something is missing” in their CR knowledge, but…“I don’t know what I don’t know”. This phenomenon was
referred to as “unconscious incompetence” by one practitioner.
Participants discussed the lack of appropriate supervised placements for undergraduate students, particularly in
small towns or communities that had limited capacity to accommodate them appropriately. They also noted that
there was a lack of funding for supervision, which influenced the availability and quality of placements. The
result was that students in some areas were not gaining skills in CR through their placements and were not
being adequately prepared for community work.
…What worries me is that they’re…[university departments]…put[ting] them [university students] in
unrelated…placements that aren’t clinical…they put Occupational Therapists at Coles or Franklins…for 14
weeks. Not under an Occupational Therapist but just to look at processes in a supermarket chain or…very
broad issues. But they’re not developing their community skills.
Other participants expressed that because of the low profile of CR, students were often “herded” into work in an
acute context after University, with minimal encouragement or exposure to give community work a try. Although
a limited number of community-related subjects or placements were available in some degrees (e.g.,
Community Nursing), there was a general consensus that most practitioners graduated from university with no
intention of working in community settings and no knowledge of their community options. “I never thought of it
[working in the community]”.
Insufficient Organisational and Community Resources
An overwhelming theme discussed by most participants was the “lack of time and resources” to implement CR
effectively. Most participants highlighted lack of time, lack of funding, staff shortages, the lack of “a rehabilitation
team”, “huge caseloads”, “lack of community resources”, lack of information and no technology. Participants
commented that the lack of resources, time, staff and huge caseloads compromised their ideal practice
environment. Although they would have liked to work with Consumers in their own home environment, with their
natural supports to facilitate the transfer of skills into the real world, they were “not able to”.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
94
...time and resources. I don’t have the luxury of being able to do that [home visits, intensive support]
because the casework demands are just so huge that you aren’t able to do that yourself. You can give
people ideas and strategies and say, ‘go away and try it’ but you don’t have the ability to actually provide
that type of support.
Many participants complained of having the time and resources to only apply community band-aiding and
“quick fixes”, but lacked the time and resources for intense rehabilitation or follow up.
Lack of time was most frequently mentioned by participants as a barrier and was specifically blamed for:
x Inability to provide a holistic service
x Lack of opportunity for formal team planning and
x Inability to provide every Consumer with a full service.
Some participants described how the lack of time resulted in the need to adopt a “general approach” [i.e., one
size fits all]. Although many participants were aware that a “Consumer focussed service means you can’t fit
everyone into the same box”, they believed they were unable to change the ‘status quo’ due to the lack of time
and resources. As one participant concluded:
…because I don’t have a lot of time to get out…I think some people do feel a lot more comfortable in their
own homes and they would probably prefer it if I come and visit them there and do their therapy in their own
house, but that’s a luxury…if people can come to me well that’s the preferable way to do it.
Participants admitted to becoming impatient and rushing Consumers, which they believed was
counterproductive to the process of CR. Many participants were aware of the importance of taking the time to
“be caring and talking to people”, but noted that their “lack of time” hindered collaborative relationships with the
Consumer and was not conducive to a Consumer-focused environment.
Personal feelings of becoming “overwhelmed” by heavy caseloads, not having sufficient time to address
administrative tasks and feeling unable to cope with any more new referrals were prevalent in the Interviews.
“You’re under a lot of pressure, when there is a lot of new referrals and that sort of thing, the paper work can
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
95
often slide”, “look I can’t cope with the number of referrals I’m getting”. They reported that due to time
constraints, often only basic safety needs were addressed for many Consumers -- “…[we] skirt around the living
skills stuff because there is just not the time…they don’t get the rehabilitation that they need because we just
don’t have the time, so we just make sure that they are set up and safe”.
Many participants believed that time management was directly linked to inappropriate levels of staffing. They
stated “time management strategies will not solve the problem - more staffing will”. Lack of staffing (in addition
to time) was seen as an overwhelming barrier. Most participants reported that limited staffing was a barrier to
providing a holistic service and spending adequate, if any, time in the community. In relation to staffing
shortages, participants reported that there was a lack of incentives to take up and remain in CR positions,
particularly in rural/remote and Indigenous areas due to the low profile of CR. As a result, staff were constantly
changing and “continuity of care” was compromised. Many participants believed that their organisations were
not responding sufficiently to the risk of workforce shortages and retention problems.
Another significant theme in the data that related to staffing shortages was the lack of administration support for
practitioners, some of whom relied heavily on Therapy Assistants (TA) to fill this role. Most of these participants
believed it was a waste of the TA’s potential and prevented them from contributing to CR delivery.
…one of the mistakes that we’ve made here is that we don’t have a lot of admin support in Allied Health so
that the Therapy Assistants have taken on some what of an administrative role which is dumbing them
down. They’ve got greater potential then that and I hate to see Therapy Assistants photocopying for
example, or typing statistics into a computer. That’s not what a Therapy Assistant should do I don’t think. A
Therapy Assistant should be doing stuff with the Consumer.
Some participants identified the lack of administration support was “a make or break issue” for their service,
particularly in the first year as staff required “extensive support to organise their travel, paperwork … if they are
to be retained”.
The community context itself generated a resource issue for practitioners in that the lack of community
resources compromised CR implementation. Many participants commented on how the metropolitan context
provided more choices of services, less staff turnover and fewer delays in accessing services for Consumers. In
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
96
contrast, rural remote and Indigenous communities lacked resources and necessitated a more creative
response by practitioners. “There are a lot of areas that need rehabilitation but in saying that sometimes there is
a lack of resources available and we feel like we are failing at times”. Even basic community supports (e.g.,
support groups, community services etc…) were often unavailable.
Lack of Technological Skills and Resources
Many participants raised the issue of their lack of access to the Internet and electronic resources, which
prevented their access to forms, information, resources, and innovative service delivery methods. This lack of
knowledge and access frustrated practitioners and caused significant time delays. Practitioners noted that it
was critical to have accurate and current information via websites, particularly orientation manuals and profiles
of communities or organisations. They also described being “left behind” by Consumers who had access to
Internet resources and expected the same level of knowledge of their practitioners.
Lack of Structured Protocols and Documentation for CR
Many participants reported the lack of formalised processes and protocols for common CR tasks such as goal
setting, planning and progress documentation. This lack of protocol has resulted in inconsistency of
implementation and has allowed a range of non-CR practices to eventuate. The lack of structured protocols and
guidelines was also thought to expose practitioners to legal implications. Referrals processes were also
described as “inconsistent across providers, organisations and contexts” (e.g., hospital to community) and
many participants felt there were no formal procedures to guide practice.
Lack of Evidence Base for CR
Many participants reported lacking the “evidence base” that underpins CR. Several participants believed that
access to this knowledge would have been beneficial in setting up new services, especially in relation to the
advantages and disadvantages of home-based or centre-based services. “I’m not sure if I know what the
evidence base is for [CR] …whether it's better to deliver your services in a clinical setting or a home-based
setting, there’s a lot of pros and cons for each”. This quote illustrates a general lack of understanding about the
principles of CR. One participant commented that practitioners were skilled clinicians but not “skilled evidence-
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
97
based practitioners”. Also mentioned by participants was the lack of support and guidance to establish and
conduct research projects of their own – “…We don’t really have anyone or a department or an area that we
can go to [for research support] and I see that as a big barrier…that’s why I kept up with the University … that
was fantastic”.
Workplace and Job Structures that Prevent CR Practice
Most participants identified the lack of information and preparation that was available when they had entered
CR. Their tasks and roles were varied, “challenging”, unfamiliar and described as “scary”. One participant
described the transition and lack of orientation into a new CR role:
…I started quite a new role…it was a little bit different and it was something that no one really knew a
whole lot about. So I was in a really unstructured position…A very minimal [orientation]…that was definitely
lacking. In hindsight I can say that.
Participants spoke emphatically for the need for clearly defined roles and job descriptions within CR and the
importance of supportive leadership, and many reported dissatisfaction with the leadership they had received
“…I don’t know any leadership”. According to other participants, they worked without supervision or leadership,
but as a result, there was no support, promotion of CR, or protection of their rights as employees. Many
participants had also experienced poor communication with management and reported that interactions with
leadership “…wastes time and nothing [is] achieved”, usually due to the lack of CR understanding among
management. Participants reported that their Line Managers often failed to understand Allied Health practice
and rarely embraced a community model. As a result, their leadership style often prevented productive
collaboration and risked staff retention in CR.
…one of the big problems is line managers, in that a lot of line managers are very focussed on numbers.
So we want to get our stats up, we want to make sure we’re seeing lots of patients. Because that looks
good for us…That mentality…We had a dietician who was really wanting to look at more broad based
diabetes services throughout the district and she got rapped over the knuckles quite severely because her
numbers weren’t as high as the OT and Physio who were putting lots and lots of people through outpatient
clinics and that sort of stuff, and why wasn’t she doing that…and the clinician ended up leaving and going
to the metropolitan area.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
98
Lack of Flexibility and Confusion about Eligibility Criteria
Practitioners believed that CR should be based on models that are flexible and can adapt to the economic,
political, geographical and cultural diversity of their specific environments. However, the implementation of CR
is often guided by policies that have been influenced by traditional health system models and eligibility
determination processes. Many participants believed that the eligibility criteria were open to interpretation and
reported that access to CR services “depended on who you talked to”.
…you may have the same funding type and I’m saying well they’re eligible and someone else is saying well
they aren’t…they [eligibility criteria] become a barrier, that we possibly have the ability to be more flexible
than we do sometimes
Participants stated that the variations in CR eligibility criteria (and interpretations of criteria), both across
services and across individuals within services was a serious concern. Further, making sense of contradictory
eligibility criteria within the community service system occupied much of the CR practitioners’ time and energy,
often with little tangible outcome for Consumers.
Lack of Recognition of a Specialised Role
Some participants believed that there was a need to acknowledge CR as a specialised role that required unique
competencies. This was particularly the case for practitioners who were working in remote areas or specific
communities:
…we are really trying to…foster the thought that working in a remote area is a speciality, and just like you
would move from paediatrics to intensive care, they are two very specialist areas, but just because you
move doesn’t mean you’re not a specialist anymore…we don’t take just anybody…you will receive support
and training, but it is a speciality in itself…the remote Allied Health practice is your speciality.
Many practitioners voiced the concern that the language associated with their title was often misunderstood and
“does not clearly convey to others what the role entails” [e.g., CR practitioner, Diversional Therapist]. In a
related concern, some practitioners indicated that they did not have the same status as other professionals
within QH, particularly in the acute treatment sectors, and that their CR services were considered “an extra” that
could be eliminated if necessary.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
99
…Allied Health [practitioners] aren’t considered as important. When you look at anything to do with
Queensland Health, it’s like, doctors and Nurses, that’s been the traditional areas [of importance], and so
Allied Health are an extra… CBR is across all those [Allied Health, doctors, Nurses] streams. So…when
you look at core competencies, it shouldn’t be just linked to a particular discipline [the competencies should
apply to everyone in CR].
Some participants described how CR could respond to issues that may be very discrete or seemingly
insignificant, but have a huge impact on Consumers’ lives (i.e., the ability to communicate one’s needs and be
understood, the ability to swallow etc.). These difficulties were seen as being at the “core of human needs”, but
remained unrecognised as a high need issue. If one cannot eat or communicate, it impacts on Consumers
socially (e.g., networks break down) and emotionally (e.g., frustration, loss, etc). “I think they’re very discrete
difficulties and I think they’re underestimated because of that. And staffing wise, I certainly, have a lot of
difficulty getting those areas recognised as being high need”. The fact that CR provided critical services to
Consumers, but did not appear to be valued within the broader health agenda, was a major disappointment to
practitioners.
Vulnerability as a Result of CR Practice
Many participants expressed concern for their personal safety either within the community, the Consumer’s
home, travelling the roads or working in isolation and dealing with “difficult” Consumers. Although some
participants felt they could handle many of these challenges, there were legitimate issues that arose for CR
practitioners that could prevent them from implementing good practice.
…[It] was a little bit daunting at first because of his [Consumer’s] erratic behaviour…the other girls
[therapists] who had to go and do the exercises with the mother who is 96 [years old] were quite put
off…They felt they were not comfortable [but] it didn’t bother me.
Participants commonly noted concerns for their personal safety when in a Consumer’s home or visiting
particular communities. Many reported “feeling unsafe” due to a range of factors, many of which were based on
actual experiences (e.g., dogs, dirt roads in the wet, no phone access, people hiding out in the bush, being
locked up, car keys stolen while at a Consumer’s house).
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
100
we are going to a potentially threatening environment…there might be a violent family member…that we
don’t know about…the hospital wasn’t aware…I worked with one of the social workers who got locked in a
chook pen…one of her Consumers locked her in the chook pen…it was not funny, because we all went
home, and she hadn’t got back from home visits, and everyone went home…what kind of precautions are
there for us…and other Physios actually…came up from [regional town] to see someone…and the son took
the car keys…she went to go and couldn’t find the car keys, and the son had a mental health issue…and
he took the car keys.
…Health and safety…If you’re working in a person’s home, you have to be aware of your surroundings so
that you don’t get injured and your Consumer doesn’t get injured. When you’re going into people’s homes,
safety…you don’t know where you are and it’s personal safety more so than workplace health and safety.
You haven’t got the safety net of the hospital and you sometimes have no warning of the type of situation
that you are walking into.
These examples highlight an urgent need to develop a system of workplace safety that can respond to the
particular challenges of community work. They also highlight the need to develop competencies in CR
practitioners and support personnel that can facilitate their ability to identify and minimise risk. Finally, there is a
need to ensure opportunities for debriefing and counselling for CR workers, particularly those who are not
supported within a team environment.
Another important issue raised by practitioners was a general lack of focus on their own personal health and
well-being while serving the needs within their communities. “I would get back to the clinic at the end of the day,
I'd be exhausted, I hadn’t drunk enough [water], had a headache, I was dehydrated".
For many CR practitioners, their context required them to work autonomously in the community, leading to
feelings of isolation, especially for those in remote locations without team support. They recognised the
importance of professional support.
…Just having really, making sure that they recognise the importance of those professional ties and the
supports available from a number of different avenues. So they don’t feel like they’re a sole Speech
Pathologist working in, whether it’s a community health centre or a rehabilitation team or whatever. But
they’re only a phone call away, only an email away, and if they do need some help, there are resources to
use.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
101
The Assumption of Knowledge
There was a general consensus among participants that “everyone thinks they know what CR means” and that
this assumption of knowledge created barriers to implementation of CR, standards of practice and training.
Some practitioners raised concerns that CR was vulnerable to a multitude of unique perspectives and
understandings. Some practitioners were unwilling to seek input from others about their perspective.
New graduates
Participants commented that as a new graduate or when working with a new graduate there often was the
assumption and/or expectation of knowledge based on the fact that they had recently completed university
training. However, it was more common that graduates had not developed a community framework to guide
their practice. Many felt “disheartened” when faced with the reality that they did not know everything.
…one of the best things she [mentor] ever said to me was ‘at uni they give you tools and it’s not until you
get out that you use them and you learn the most’…you…go through uni expecting that you’ll know stuff.
But she said that all of your learning starts once you’re out. And that was a big learning curve because I
was really disheartened when I wasn’t knowing things, but yeah, looking back I’ve learnt so much more just
being on the job.
Complacency and Maintaining the ‘Status Quo’
Some participants identified the fact that the assumption of knowledge was not always naïve as in the case of
new graduates, but was based on an “old school thought of practitioner knows best”. These practitioners who
operated from this basis were observed as setting goals for their patients with little consideration of the patient’s
perspective. They also failed to question their own knowledge systems or reflect on the adequacy of their
practice models.
…. I think certainly think that [expert model] still continues to a certain extent, you’re the therapist, you set
the goals for the person, you do an assessment you say this is what they’re really having trouble with so
let’s work in that area.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
102
Setting goals for Consumers without engaging them in their own rehabilitation process directly contradicts the
core competencies of CR, namely Consumer engagement and holistic practice. However, it was clear from the
data that some practitioners failed to adequately implement this model. It was acknowledged, however, that this
rejection could be deliberate, the result of non-reflective practice or due to a perceived need to operate from a
different framework.
The Perception that the Consumer is the Problem
Some participants reported that the motivation and commitment of the Consumer correlated with the context of
the rehabilitation environment. Consumers who came into centre based rehabilitation settings were perceived
as motivated whereas Consumers who received home visits were sometimes perceived as ambivalent about
rehabilitation. Other Participants articulated that often working within the Consumers’ home environment could
be considered distracting, lacking resources and time consuming. The unstructured nature of the home
environment and lack of resources as compared to a hospital environment, were construed as barriers and
Allied Health practitioners felt that the Consumer was in charge in their own environment and felt they didn’t
always cooperate.
Practitioners also commented that some consumers lacked the “desire for independence” and that this was a
barrier to CR. According to some practitioners, it was the Consumer’s responsibility to embrace independence
and they [as practitioners] must not impose their own goals. However, it was clear that many practitioners
lacked the skills to assist or engage with Consumers to achieve their own goals. When Consumers refused to
set “appropriate and realistic goals”, accept services, missed scheduled appointments or were “difficult to work
with”, many practitioners were at a loss about how to proceed. They appeared to embrace a dichotomous
definition of independence, either expecting Consumers to be self-determined without appropriate support or
inadvertently encouraging dependence on the therapist. The intermediate concept of inter-dependence and the
importance of the relationship were not evident in much of this data.
Lack of Person-Job Congruence
Many participants described how a constellation of practitioner qualities made them suitable or unsuitable for
CR practice. For instance, personalities, poor interpersonal skills, judgmental attitudes, impatience, arrogance,
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
103
lack of a Consumer-focussed approach, the need for personal gain and inability to be flexible were all thought
to negatively influence the implementation of CR. Participants acknowledged that personality varied greatly
across practitioners - some are introverts, some are extroverts, some are confident and others are not. Many
variables (e.g., training, experience and how much support they receive, the nature of the community etc.) were
thought to interact with each practitioner’s unique personality style to determine their ability to adapt to and
embrace CR. However, it was generally agreed that some personality qualities were essential and some
signalled a likely clash with the CR model. These statements were numerous and reinforced the conclusion that
knowledge and skills are necessary but not sufficient for CR. Having the right attributes and values to underpin
CR was critical.
…a lot of it is your personality and the way you perceive life. There are some arrogant people out there who
shouldn’t be doing the jobs that they do. Some people don’t take on board that they need to act as part of a
team, you know, they know everything, they don’t need to sort of bounce things off other people.
Participants commonly referred to judgmental attitudes as a barrier to CR, “you can’t be judgmental of people
and their backgrounds”. Participants believed that some practitioners regularly made unconscious judgements
about other cultures, which impacted on their practice – it was acknowledged that these judgements were often
made without awareness, “I just realised how naïve I was. I grew up thinking I’m not racist, everyone’s equal.
But I guess you do unconsciously make judgements, your values are always there”.
Participants commented on the importance of being flexible and accepting challenges, particularly in remote
locations. “Out here we do have some very remote, varied …contexts compared to the other centres, and often
[there can be] … fairly challenging circumstances, particularly in the Indigenous communities”. Participants
believed that some practitioners adopted the “one size fits all approach” and were unable to modify their
behaviour if that approach did not work. It was noted that the Consumer was often blamed for the failure of this
approach (e.g., resistant, non-compliant etc.). However, it was also noted that inflexible models of operating
may be emanating from the service philosophy or other physical constraints.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
104
Lack of interpersonal skills, self-reflection and Consumer-focus
A very important theme to emerge from the data was the fact that many practitioners believed they or their
colleagues lacked “people skills” – the interpersonal skills that were necessary to facilitate CR. In particular,
practitioners commented on a lack of, or inability to engage in, reflective practice together with a lack of a
Consumer focussed approach to communicating.
… they just say things without giving it any thought they are too blunt and abrasive and not understanding a
person, impatient because they [Consumers] are slow … there are people who can do this sort of work and
people who shouldn’t …
…sometimes the levels of patience and compassion might be a little bit lacking.
In confirmation of the impact of poor interpersonal skills, most participants commented on the importance of
good communication skills and the significance of listening to the Consumer.
…you have to really show them [Consumers] patience and understanding that I might not get what you
mean now, but I will wait and listen. And even if it takes you half an hour to tell me what it is that’s bothering
you, I’m going to wait, I’m not just going to bop you off because you’re wasting my time.
The “lack of Consumer focus” was described by a number of practitioners. They believed that many CR
practitioners tried to inappropriately control the rehabilitation process. Some commented that practitioners
forced the process to follow a particular direction, without letting Consumers determine their own focus and
guide their rehabilitation. As one practitioner concluded, “I think it [rehabilitation] needs to be Consumer-led”,
but this was not always the case.
In line with these comments about Consumer-focused practice, practitioners noted that the ability to engage in
reflective practice was missing in some instances. Participants commented that some practitioners in CR
appeared to lack insight into areas of their practice or behaviour that required improvement and this was a
significant barrier to ensuring good CR models could be developed.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
105
…there are some things that you can teach some people and some things you just can’t and the worst
thing is when someone thinks they are just a really good communicator and they are really not. How do you
make them, you know, if they are insightless - how do you instil that [insight]?”
Being a team player
Personalities were seen as being an important element of good communication and teamwork, and could be a
barrier to good CR work. Interpersonal skills were required for teamwork and collaboration, both internally and
externally. The CR role involved dealing with many different people and forming alliances with many different
community stakeholders. The practitioner’s attitude towards being a member of a team was, therefore,
extremely important in CR.
…You can’t go out there and say that it’s all about me; I know what’s best. You have to be able to work
within the team and utilise the skills of each person in that team to achieve the best that you can for your
patient outcome. How well they communicate with each other, whether they listen to advice that’s offered or
given. Whether they willingly accept feedback and ask for feedback…?
Adaptation to a CR Role
As one practitioner noted, “some people can’t adapt to different environments. I think they have to be prepared
for that [in CR] because it is a shock and you have to be able to adapt”. This statement exemplified the view of
many participants regarding their role in CR. Personality and personal preference were seen as contributing
factors to their adaptation to a CR role. Some practitioners stated that they preferred to work in a controlled,
structured, environment whereas community practice provided less structure. “[The acute context] it’s very
controlled. And I think that depends on what type of person you are. I’m a little bit more obsessive compulsive
so I like that control, I like to know where everything is. …I think it’s a very personal”. Practitioners noted that
some people may lack confidence to “give it a go“ when required to perform tasks that were not discipline
specific. To protect themselves, they reverted to a functional model of practice.
… people say they don’t know anything about spinal cord injury, And we say that’s fine you don’t need to
know about spinal cord injury to work with someone’s shoulder. People put up a barrier for not knowing –
then you have those that are scared…
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
106
Participants noted that sometimes when you do “have a go”, you can make mistakes. However, they believed
that practitioners should accept that mistakes do not happen often and that they are an important source of
learning if managed sensitively.
…learning from your own mistakes but not being so hard on yourself when you do something that [doesn’t
work out]. If it doesn’t work, then you know, you can change that and learn from it and because of this, it
works better.
Clinical-Focused Practice
There was considerable evidence that many current practitioners were only comfortable with “one-on-one”
clinical work. Some reported being frustrated with “slow pace of community”, felt “unchallenged “ and were
disappointed by the lack of efficiency and economies of scale in CR practice. These practitioners reported that
they were used to the fast pace, pressure and highly structured environment of inpatient settings, where
throughput, intensive treatment regimes and speedy discharge were valued.
…I like working … under pressure. I think a lot of clinicians do because it gives you an edge….in the
community it's a different, it's learning to, it's a lot slower … it's a different type of setting all together.…that
is difficult to get use to, so I don’t know the solution around that, but it's just learning to be able to structure
your day.
…You see a lot of people struggle when they first come and they’re used to maybe seeing someone every
half an hour. That really clinical role where it’s very timely and they have to see so many people in a day. It
just doesn’t happen like that, you have to really take a step back and like, look at your, I guess, realign your
goal posts...I actually went out into the community on my second day of work. They do kind of warn you
that it’s coming. But even so, when you’re coming from a background where you have been seeing people
back to back all day you sort of feel ohh, I’m wasting time.
… I’ve certainly seen clinicians on the team who don’t enjoy that model [CR] of working and they’ve been
able to identify that … if you come from a high pressured, hospital situation where it’s all efficient, and then
you come to a team like ours where you’re in the car for two hours and then you do a home visit. It doesn’t
feel efficient. So they can feel frustrated and not so challenged in those situations.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
107
Contextual Barriers
Some practitioners raised issues created by the need to visit Consumers in their home environment. The
unstructured nature of the home environment compared to a hospital environment was construed as a barrier to
effective practice. These practitioners noted that Consumers were in charge in their own environment and
“don’t always cooperate”. Although these views were disturbing when compared to the principles of CR, there
were some legitimate barriers created by the home environment. For instance, one practitioner stated that it
was difficult to work efficiently in the home environment.
…making sure we’ve got all the things that we need, we can’t really carry a huge amount of stuff, have
everything on hand, and sometimes, you know, home settings might be a little more distracting or there
might be other people around.
Sometimes equipment was ineffective in the Consumer’s home environment and several practitioners found it
challenging to adapting equipment from a hospital setting to a home environment:
…they’re going into homes of varying degrees of … levels of comfort and equipment and all those sorts of
things. I think that … flexibility in being able to deliver the services in situations - if you’re only used to
working in hospitals, for instance, would be quite challenging.
Participants also emphasised the point that it was important to meet Consumers in an environment that was
conducive to communicating clearly and where Consumers, family members and Carers felt confident about
discussing their problems or needs. Many participants confirmed that clinic-based service delivery was easier
than home-based services and perceived that, in some community settings, centre-based clinics could facilitate
a more efficient use of resources. One participant stated that the time that was gained by delivering centrebased services allowed CR staff to familiarise themselves with CR strategies and to establish their scope of
practice.
An interesting paradox arose in the discussions provided by some members of the new CR teams across
Queensland. For instance, some teams discussed the fact that they were currently encouraging centre-based
rehabilitation because it required commitment on the behalf of Consumers and was more efficient in terms of
resources. They indicated that they were “too busy” to do home visiting unless it was considered essential (e.g.,
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
108
due to Consumer transport difficulties, cognitive or language impairment, or need to observe the home
environment). However, in an apparently contradictory statement, they indicated that they intended to increase
home-based services in future. Unless significant resourcing issues were addressed, it was difficult to
determine how centre-based services would be replaced by home-based services in future.
Lack of Pre-service Education and Preparation for CR
Lack of knowledge and experience in CR, lack of core competencies across disciplines and limited
opportunities for CR training and professional development have the potential to result in systemic CR
workforce problems. Participants reported a lack of appropriate training to prepare them for CR roles, both in
their tertiary degrees and in any post-university education/training. Several participants believed that there were
human service disciplines that provided broader training than that provided in the Allied Health and Nursing
disciplines (e.g., social work, psychology) and that some Allied Health practitioners were more prepared than
others. Generally however, participants agreed that new Allied Health graduates were not sufficiently trained to
meet the challenges and competencies required for CR delivery, particularly in rural and remote communities.
New graduates themselves commented on the fact that there was a singular focus on their clinical discipline.
Their training did not prepare them for a multidisciplinary approach, nor for the realities of work in small
communities. “I really didn’t come out [of University] having much of an idea of what happened in the other
disciplines”. More experienced CR practitioners agreed that they had not been prepared for community
practice, but hoped it had “changed since then”.
Lack of Community Awareness – ‘Culture Shock’
Lack of exposure to and preparation for community work was described as “…a shock”. Most importantly,
participants reported lack of awareness of the “rural context” and considered this to be a major barrier to both
new graduates and experienced staff. “I had absolutely no idea”. Many practitioners had no idea of what
happened in remote communities and reported disbelief at how many people needed help. Participants who
had worked in remote areas reported an even greater lack of awareness and noted that new staff usually
lacked any preparation for a remote context. “I very much I felt like I was in a developing country - and some
previous awareness of that - of things that I might expect would have been really useful”.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
109
And I think you need to be prepared. It’s a shock, seeing the way people live, and you can’t walk in a go oh!
Look at this house! You’ve got to try and keep a straight face and be pleasant and you know, it might not be
their fault that they live that way. They might not know any different. That’s all they can afford. So I think be
prepared, to know what to expect.
Emotional and psychological issues
Participants reported that most students on placements, new graduates and experienced CR workers lacked
the skills to handle emotional and psychological issues. Given the nature of CR practice, practitioners were
often the first contact with Consumers and had to be able to recognise and manage these emotional situations.
Lack of training in dealing with psychosocial issues was a significant barrier to the effective implementation of
CR. For example when faced with a Consumer and/or family who needed to talk to someone immediately, not
knowing what to say or do was daunting for most practitioners. “As any Allied Health professional will tell
you…you do so much counselling but we are never trained for that”. Participants agreed that CR work was
often very confronting. The nature of community work – working with families in crisis and people who are
dealing with grief, loss and depression – trying to make sound clinical decisions when faced with the realities
and hardships of people’s lives and environments was extremely challenging. Interestingly, the focus of this
barrier was the practitioner rather than the Consumer.
…you’ve got this family, maybe lack of food, lack of resources, … [CR work] can be very demanding. And I
think as a student, I wasn’t really able to cope. I found I’d go home in tears because it’s so confronting. Just
being able to deal with grief and decision-making and our clinical judgement as well.
Many participants emphasised their lack of skills to manage the emotional impact of CR practice on them
personally, particularly following exposure to stressful or dangerous situations such as abusive Consumers,
“observing the way family members treat each other”, delivering bad news or a Consumer dying. The
participants observed the need to implement debriefing and counselling options to assist them in managing
their own emotions. Some participants described their encounters with difficult or abusive Consumers to
emphasise the need for debriefing, “And he just started yelling abuse at me and saying he was going to sue me
… I needed debriefing afterwards because I was feeling quite fragile. It’s not nice being yelled at.…I did get
upset, I cried”. Participants felt that appropriate members of the team (e.g., social worker, psychologist) should
be utilised to develop policies and procedures to guide other practitioners in how to handle challenging
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
110
situations that are beyond their own professional expertise, but also how to manage their own responses to
those situations.
Interestingly, a few participants believed that clinical issues were always a priority and that addressing
psychosocial issues was only necessary to enable practitioners to deal effectively with a clinical issue. For
these practitioners, the importance of emotional and social difficulties was acknowledged, but only in that they
detract from clinical outcomes.
…When I deal with people who have chronic problems or problems that overwhelm them, I might start out
doing clinical stuff and then you ditch it because there is no point to it if they’re unhappy and not achieving
what they want…you find yourself counselling all the time and not getting on with the clinical stuff - it’s no
good, we need to get on with the clinical stuff but you do it by helping them work out their [psychosocial]
problems.
Maintaining Clinical Competence
Many participants reported that their involvement in CR was a significant barrier to their discipline-specific
career development. They were worried about the fact that their lack of practice in clinical areas could result in
skill loss. “You might be working in a community and you see something acute once every now and then and
you’re not practising it regularly”. As a result of clinical skill loss over time, the practitioners reported that
Consumers were sometimes referred back to the hospital for treatment of specific conditions. This situation
created a difficult tension for practitioners and a potential costly duplication for the health system. Practitioners
reported that there was a need to assist practitioners to feel comfortable with this new model of operating and
to value it as a worthwhile professional activity.
…In the first 6 months, they are losing their clinical skills because they are maybe not seeing clinical
[patients]…anymore, and they find they are doing more consultancy type work, and community group work
and some of the broader primary health care activities…and it takes people a while - to make people feel
comfortable that that is still a professional activity.
Some practitioners concluded that they required opportunities to keep their clinical skills up-to-date if they were
to continue working in community settings. However, other practitioners reported that their role required them to
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
111
constantly shift between discipline-specific work and community practice, and that this was extremely difficult.
They reported that this broad scope of practice could undermine the quality of CR and its outcomes:
…the other challenge that is very relevant in this particular position, you are working across lots of different
areas rather that just focusing on CR so there’s that having to have a generalist approach and jumping form
one thing to another you jump form inpatients to paediatrics, to a burns patient, then out to the community
and it really is a very challenging thing to manage where if you were to focus specifically on CR I think you
would do a much better job and get a better outcome.
Participants agreed that this broad perspective of practice “tends to get easier with experience” but would be
extremely difficult for a new graduate.
Solutions as Suggested by Participants
Participants were asked to generate solutions that would address each barrier they identified. These solutions
are presented in Table 14 below.
Table 14: Summary of Barriers, Issues and Solutions Suggested by Participants
Barriers and Issues
Systemic Issues
Associated With the
Lack of Profile for CR
Solutions Suggested by Participants
x Advertising to raise the profile of CR
x Encourage practitioners to give community setting a try
x Rotate positions between hospital and community to foster respect and
shared learning
x CR placements (e.g., CR Team) are critical for students to develop skills
and to entice students to work in the community
x CR practitioners must be strong advocates for their profession
x Consultation between departments (QH, DSQ, CDHA) – a bottom up
approach
x Develop a framework to guide CR
x Develop competencies that cross all disciplines
x Bring all AHPs together instead of separate disciplines
x Raise awareness of what CR language means
x Someone needs to drive CR - create interest, linkages and keep it
progressing
x Consult with the right people who are REALLY doing CR - both nationally
and internationally
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
112
x Develop incentives to entice people to CR
x Create networks of support – a valuable resource for information sharing
and communication
x CR practitioners should take initiative to source information and draw
together existing resources to up-skill themselves
x Link new graduates (or practitioners new to CR) with a mentor for
reassurance and support
x Relevant student placements in a CR setting with a multi-disciplinary
approach
Insufficient
Organisational and
Community
Resources
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Create networks to share resources
Be creative in use of community resources
Use professional networks of support without losing CR focus
Allow teams to have sufficient discussion time
Prioritise team problem solving
Take opportunities to consult with colleagues whenever possible –
spontaneous or informal discussions
Communicate concerns to manager before the situation gets out of hand
– ask for assistance
Develop formal processes and procedures to facilitate communication,
problem solving and team building
Select tools that are more time efficient
Communicate to management about time related issues
Put a plan in place to ensure efficient use of time in teams
Strategise ways to use time more wisely
Administration support must be identified as a critical issue for service
longevity
Use the technology that is available – email, photographs, telephone, or
facsimile in order to access support from other practitioners
Provide Consumers with ideas and strategies and encourage them to self
manage
Lack of Technological
Skills and Resources
x Opportunity to complete paperwork electronically would be beneficial
Lack of Structured
Protocols and
Documentation for CR
x Put protocols in writing to help guide the CR process.
x Written plans provide a guide for CR practitioner, Consumer and family to
monitor progress and keep on track
Lack of Evidence
Base for CR
x Develop partnerships with universities
x Training in evidence based practice
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
113
x Develop and evaluate models of care, relevant for this type of situation
Workplace and Job
Structures that
Prevent Good Practice
x Create websites for CR teams to share information, processes, practices
and evidence
x Recruit managers who understand CR issues
x Case conferencing so Team Leaders can determine if therapist are not
achieving their goals
x Team Leader to know what staff are doing and ensure they have
opportunities to develop and improve competencies
x No more sole practitioners – always appoint two staff members for every
discipline to support each other
x Tackle retention of practitioners
x A local orientation package with community resources identified to
accommodate changing staff
x Developing leadership skills
x Develop formal processes and procedures to facilitate communication,
problem solving and team building
x Establish mentoring programs
Lack of Flexibility and
Confusion about
Eligibility Criteria
x
x
x
x
Lack of Recognition
of a Specialised Role
e.g., Remote Allied
Health Practice
x New Graduates require a very thorough orientation process and the
opportunity to learn experientially
x Foster remote Allied Health practice as a specialty
Vulnerability as a
result of CR practice
x Teach strategies to maintain personal health and well-being while out on
the road all day – (e.g., hydration, nutrition, etc…)
x Develop formal processes to deal with traumatic events – including
debriefing opportunities for staff
x Develop skills to manage difficult situations (e.g., training and education
in conflict resolution, behaviour management and interpersonal skills)
x Develop skills to manage the emotional impact on self, following exposure
to situation (e.g., opportunities to debrief, manage emotions etc)
The Assumption of
Knowledge
x
x
x
x
Allow time for practitioners to get to know the local community
Set up formal co-ordination and continuity processes
Develop skills to manage frustration
Train assertiveness without being aggressive and difficult – interpersonal
skills
Normalise the need to ask for help
Provide CR mentors
Value experiential learning
View mistakes as a learning opportunity
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
114
x View the need to learn and develop skills positively as an area to improve
x Encourage sharing of knowledge with others
x Need support, supervision, guidance and education from someone more
experienced
The Perception that
the Consumer is the
Problem
x Develop thorough understanding of behaviour
x Goal setting training
x Working with family as well as individual requires new skills
Lack of Person-Job
Congruence
x Encourage daily plans for practitioners so they can structure their day
x Facilitate ability to work in teams
x Encourage openness to advice and feedback from others through formal
recognition of this process
x Promote awareness of surroundings among practitioners
x Identify preferences of practitioners early in their employment – some
people are more suited to the hospital context with high pressure, patient
through-put and efficiency whereas others value community role
x Choose staff who: are adaptable, like a challenge, like an adventure,
have the ability to think on their feet, demonstrate a willingness to say ‘I
don’t know’ and confidence to find out the answers
x Monitor the fit between the right person and the role
x Provide a thorough orientation period
x If you get the right person, you can support them through this transition.
Provide support through various existing programs (e.g., through
workforce training units, etc)
Clinical-Focused
Practice versus
Client-Focused
Practice
x Goals and rehabilitation process must be Consumer lead – there should
be checks and balances to ensure this occurs
x Time must be allowed for practitioners to understand complex issues from
Consumer’s perspective
x Access to resources should be increased at a number of levels - Clinical
resources, Databases to develop contacts and seek evidence to
substantiate work, and community contacts
Contextual Barriers
x Facilitate move towards more home based services in future so it
becomes standard
x Work in teams of two (experienced with non-experienced, physical with
psychological, practitioner with consumer support worker)
x Formal training to alert CR practitioners to the issues they might face in
home environments
Lack of Pre-service
Education and
Preparation for CR
x Formal orientation to a new role or area
x Provide opportunities to experience different work environments
(rotating placements)
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
115
x
x
x
x
x
x
Encourage learning from Consumers
Recognise the rewarding nature of the work and the contribution made
Student placements in a CR setting with a multi-disciplinary approach
Raise awareness and expectations of what to expect in remote context
Provide opportunities to shadow more experienced practitioners
Restructure university training to provide a general year shared by all
Allied Health practitioners or a core subject that focuses on skills used in
CR
x Raise awareness and educate the community about CR
x Create a team with a skill mix – different perspectives on the team that
brings new ways of doing things
x Developing networks and links to tap into skills of experienced
practitioners working in the area
Emotional and
psychological issues
x Establish debriefing processes and co-worker support systems
x Include appropriate members in teams (e.g., social worker, psychologist)
x Develop policies and procedures to guide other practitioners on
challenging situations that lie outside of their professional expertise
x Provide relevant training opportunities
x Develop good communication skills and interpersonal skills
x Educate family members and significant others of the individual’s right to
determine and control their own life
Maintaining Clinical
Competence
x Provide opportunities for some hands on clinical practice
x Help practitioner to feel comfortable with the CR model of operating and
to value it as a worthwhile professional activity
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
116
Education and Training
117
What competencies require further education, training and enhancement?
What are the different needs across disciplines, experience levels, contexts and organisations?
This section of the report examines the training needs identified by current CR practitioners, educators and
consumers.
The first part describes the general areas of training need identified from the survey data. Particular
attention is given to discipline, level of qualification, experience levels, work contexts and organisations. The
issues identified by CR practitioners as being areas in need of training are incorporated into the relevant
competency domain. The data that informs the practitioner issues include (1) any specific topics identified
during interviews with CR practitioners and educators, and (2) areas identified by Consumers as being in
need of change.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
117
Areas of Training Need
The competency survey revealed several areas of training need as shown in Table 15. It was clear from the
survey data that four competency domains emerged as being in need of training, as over 50% of the items
associated with the domain were endorsed by practitioners. These areas were Systems Advocacy, Service
Continuity, Cultural Awareness, and Frameworks of Understanding. Each of the ten competency domains are
presented below, with a focus on the individual competency items that were identified as requiring further
training. Interview data will be incorporated where it pertains to the relevant competency domain.
Table 15: Summary of Competency Domains requiring further training (percentage)
Rank
1
Competency Domain
Systems Advocacy
No. of Items
7
Percent of items in need of training
85%
2
Service Continuity
14
71%
3
Cultural Awareness
11
63%
4
Frameworks of Understanding
25
56%
5
Holistic Focus
26
46%
6
Community Engagement
15
40%
7
Reflective Practice
19
36%
8
Boundaries and Safety
20
35%
9
Networks
20
30%
10
Consumer Engagement
16
18%
Systems Advocacy
Almost all the competency items pertaining to Systems Advocacy were identified as areas of training need (see
Table 16). The high proportion of items requiring training in this domain indicates that CR practitioners may
need greater clarity about the process of systems advocacy, or perhaps felt that this area of practice was one
they intended to develop in future.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
118
Table 16: Systems Advocacy Competency Items of Training Need
Item
Competency
Items
Over 50%
agreement
*
*
*
1
2
3
Identify areas where Consumer needs are not being met in the community
Participate in the development of local opportunities for Consumers
Contribute to strategies to address gaps, barriers and inadequacies in the
community
5
Engage Consumers and community in service planning, development and
evaluation
*
6
7
Contribute to policy making activities whenever possible
Advocate and articulate the issues associated with Consumer and community
rights
*
*
Items
Over 75%
agreement
Similarly, a set of topics that only emerged for managers of CR services involved the fact that the skills required
to establish, manage and maintain a CR service were vastly different from those required to deliver a CR
service. Managers noted that the skills they required tended to be more generic, but still situated within the
sound base of the CR model. For instance, marketing of CR and generally raising awareness of its place in the
system was considered to be a managerial activity. Planning services within the context of the local community,
advocating for improved services and strategically liaising with other services were all important skills that may
or may not be relevant to practitioners. Most importantly, managers commented on the need to have strong
human resource management skills, the ability to identify good CR practice and recruit suitable practitioners,
the ability to uphold the CR philosophy against pressures to revert to more acute models of treatment and the
willingness to support staff beyond what might normally be required, particularly in rural and remote areas. This
role involved assisting practitioners to manage difficult and complex challenges in their practice and to make
shifts in their operating paradigms.
Cultural Awareness
An area of competency requiring considerable training input was Cultural Awareness. Items pertaining to
cultural context, and the cultural interaction between the CR practitioner and Consumer/community were
reported to be areas of training need (see Table 17). The interview data confirmed that practitioners required
further skills in dealing with multicultural issues, and subsequently working with communities and families in
sensitive ways.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
119
Table 17: Cultural Awareness Competency Items of Training Need
Item
2
4
5
6
7
9
11
Competency
Understand the impact of historical events on particular cultural groups
Use listening and observational skill to identify cultural protocols
Understand and respect the role of culturally respected experts (e.g.,
Indigenous Elders)
Determine how cultural knowledge translates into practice and behaviour
Seek advice and guidance from people about their own culture
Recognise individual and group variation within cultural norms
Understand the implications of culturally diverse communities
Items
Over 50%
agreement
*
*
*
Items
Over 75%
agreement
*
*
*
*
Service Continuity
In relation to Service Continuity, all items pertaining to the secondary prevention of illness and risk
management component were considered to be areas of training need (see Table 18). This finding indicated
that CR practitioners regarded Consumer self-management and health promotion or injury prevention to be an
important aspect of CR practice. There was also a high level of agreement for items relating to coordination of
services, and how to facilitate Consumers’ movement along the continuum of care. The process of educating
other professionals about the continuum of rehabilitation was identified as a training need.
Table 18: Service Continuity Competency Items of Training Need
Item
Competency
Items
Over 50%
agreement
*
*
*
1
2
3
Assist people to learn how they are going to manage their lifestyle
Encourage Consumers in planning for a healthy future
Understand the difference between screening for risk and thorough
assessment
4
Recognising and responding appropriately to potential risks to health, both
acute and chronic
Support Consumers to monitor their own condition and to take necessary
action
Understand Consumer dis-engagement and create opportunities for
engagement over time
Provide options and consider alternatives to allow Consumers choice relative
to life phase
*
Monitor and assess outcomes relevant to the individual’s context and goals
Follow up with Consumers regarding service access to ensure satisfaction of
outcomes
*
*
5
6
7
9
11
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
Items
Over 75%
agreement
*
*
*
120
outcomes
13
Educate relevant professionals about the continuum of service provision and
the role of CR
*
Frameworks of Understanding
In relation to Frameworks of Understanding, CR practitioners agreed that there was a strong need for a clear
definition of CR and the implications of this for practice in the community. Practitioners also indicated the need
for training in areas pertaining to models of understanding, alternative frameworks for understanding, concepts
of disability, cultural, rural, and Indigenous issues. They also identified the need for training in evaluating and
understanding the outcomes of CR and the capacity of services to meet the expectations (see Table 19). Given
the fact that practitioners rated frameworks of understanding as being the least important area of CR practice, it
is surprising to see such high level of training need in this area. This contradiction indicates that practitioners
may be aware of the importance of frameworks, but are completely unfamiliar with the necessary knowledgebases. Alternatively, the practice barriers identified by practitioners that prevent the utilisation of CR
competencies may feel so overwhelming that frameworks are seen as unimportant. Nevertheless, practitioners
are aware of the existence of frameworks and desired further information. The qualitative data supported the
possibility that practitioners would like more knowledge about CR frameworks, but believed that they would not
be able to implement these frameworks effectively in their current environment.
Table 19: Frameworks of Understanding Competency Items of Training Need
Item
Competency
2
3
Adopt a clear definition of CR
Recognise the practice implications of working in communities (rather than in
institutions, private practice or other discipline based service delivery)
4
Understand models of service delivery that may be used in CR and how to
implement them
6
7
Understand and monitor the expected outcomes of CR
Know the capacity of the service to respond according to the philosophy of CR
8
Understand the principles that underpin CR and how they are implemented in
practice
Understand the limitations of different frameworks, approaches or models
9
Items
Over 50%
agreement
*
*
*
*
*
*
*
10
Draw on multiple frameworks to develop an appropriate response
*
13
Understand how disability is experienced in the community
*
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
Items
Over 75%
agreement
121
14
Understanding how cultural issues influence the experience of disability in
general
15
16
Understand the challenges associated with rural and/or Indigenous practice
Understand the concept of 'rurality' and how it influences behaviour, beliefs
and interactions
17
Understand how culture impacts on the individual experience of disability and
illness
25
Seek out unwritten 'ground rules' and using them in planning and service
delivery
*
*
*
*
*
Interview data revealed that the most consistent category of training topics involved orientation to the principles
of CR, particularly for services and practitioners who are just beginning in this field. There was particular
mention of ‘orientation packages’ for new staff that included a focus on conceptual frameworks in CR, which
were also inclusive of local issues. A particularly interesting quote was provided by one of the few practitioners
who had attended training that was specific to CR:
I did the CBR course in September. CBR has such big origins in international health and developing
countries and not so much in Australia, that I found the history of it really interesting. And how it has
developed and how that could be applied to Australia. I think knowing the history you can see what worked
and what hasn’t. Or you go into it in your own community, because every community is different. We
covered the history of CBR, the different models, we also did implementation, evaluation of CBR activities
… we also went out and had a look at a program that was running north of Alice Springs. It was a lot of
general stuff about CBR. It was facilitated by probably at least four people who had extensive international
experience in CBR and a couple who were also kind of doing it in Australia as well. So those were good
kind of mix of people with experiences and ideas.
Interviewer: Do you think that type of training has a place for anyone working in this area?
Definitely, six days is even too short. It needed to be 10 or 14 or something. There’s so much to cover in six
days but it was generally really beneficial. The other thing that was good about it was that a lot of the
participants were … lots of different groups of participants who came from within the same organisation. So
a lot of the activity was focussed on how they could improve their service. And doing lots of group work and
stuff like that. But also comparing the different organisations and what they’re doing. Just getting a bigger
picture of what’s going on.
Holistic Focus
Within the competency domain of Holistic Focus, training was needed in the complexities of the mental health
system and in the way mental health issues pertained to CR Consumers (see Table 20). The inclusion of family
members and voluntary Carers and the facilitation of natural supports in CR was the focus of other training
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
122
needs in this area. Managing challenges to confidentiality in the community context was also identified by
practitioners as an area for training.
Table 20: Holistic Focus Competency Items of Training Need
Item
5
6
9
12
14
17
18
Competency
Understand the mental health system and how it interacts with other systems
Recognise mental health issues or illness and make appropriate referrals
Foster naturally occurring supports such as neighbours and community members
Use of strategies designed to strengthen families and communities
Be aware of additional challenges to confidentiality that arise from holistic
practice
Acknowledge the distinction between family and caring roles
Provide support to family members, and voluntary Carers so that they can
facilitate Consumer outcomes
Items
Over 50%
agreement
Items
Over 75%
agreement
*
*
*
*
*
*
*
19
Assist family members and voluntary Carers to adjust to their roles and
responsibilities
*
20
Implement strategies to ensure that the service is responsive and flexible
*
23
25
26
Identify technology that can support home-based service delivery
Recognise and manage challenges to maintaining confidentiality
Implement strategies to maintain relationships with Consumers when direct
contact is limited
*
*
*
The most consistently nominated area for further training identified in the interviews was psychological
knowledge and skills. This issue was the most common challenge for practitioners. Specifically, practitioners
identified the difficulty in converting ‘psychological theory to clinical practice’ and facilitating Consumer
adjustment to disability. Further, practitioners highlighted that these holistic skills were difficult to acquire, yet
their clinical practice often demanded such a skill base.
Community Engagement
In relation to Community Engagement, items identified as requiring training were those relating to
understanding of the community from multiple angles, appreciating local norms and protocols for behaviour and
promoting community capacity (see Table 21).
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
123
Table 21: Community Engagement Competency Items of Training Need
Item
2
3
4
5
8
14
Competency
Understand and appreciate how different types of communities operate
Understand the process of gaining acceptance and trust in the community
Recognise locally accepted norms for behaviour
Find the 'common ground' before acting
Profile the community from multiple angles (e.g. businesses, social networks,
processes, and geography)
Promote community capacity
Items
Over 50%
agreement
*
*
*
*
*
Items
Over 75%
agreement
*
Reflective Practice
For the competency domain of Reflective Practice, training needs were associated with critical analysis of the
evidence-base, monitoring and evaluating CR outcomes and reflecting on the appropriateness or suitability of
service provision. Supervision of Therapy Assistants also emerged as an important area and was confirmed in
the qualitative data as an issue of emerging significance for many practitioners, particularly due to legal
ramifications (see Table 22).
Table 22: Reflective Practice Competency Items of Training Need
Item
5
10
12
14
15
16
17
Competency
Monitor the cultural appropriateness of your practice
Engage in innovative use of existing resources
Collect and collate meaningful information regarding outcomes of the CR
service
Build activities that support reflective practice into workloads
Critically analyse existing evidence about CR
Be familiar with issues of outcome measurement
Monitor the well-being of Therapy Assistants who work under your direction
Items
Over 50%
agreement
*
*
*
Items
Over 75%
agreement
*
*
*
*
Similarly, Interview data indicated the need for more general practice skills, knowledge and attitudes that would
enable practitioners to work effectively in community settings. In particular, numerous practitioners noted that
they were lacking in counselling, case management, negotiation and conflict resolution skills, community
networking skills, and complex communication skills. They indicated that these skills would improve their
practice if acquired. Within this set of topics, were some broad skills, such as effective presentation skills,
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
124
problem-solving skills, technical skills, teamwork skills and managing with limited resources. These skills did not
directly impact on CR practice, but would improve practitioners’ capacity to manage their workload effectively.
Networks
In Networks, there was a particular emphasis on the need to understand service criteria, review service
availability and understand levels of government in the rehabilitation process. Items referring to reviewing and
evaluating teamwork, responsiveness of the team and efficiencies of practice and ensuring understanding of
CR among professionals external to the service were also highlighted (see Table 23). These findings reflect
some confusion surrounding the cross-sectoral and multi-disciplinary nature of CR.
Table 23: Network Competency Items of Training Need
Item
2
7
8
15
17
18
Competency
Understand the inclusion and exclusion criteria of major services
Understand the levels of government and how they interact and impact on
Consumer services
Keep up to date regarding available services
Conduct ongoing review of team functioning
Monitor and regulate team responsiveness to Consumer focussed goals
Communicate with non-Allied Health practitioners and facilitate their
understanding of CR
Items
Over 50%
agreement
*
*
Items
Over 75%
agreement
*
*
*
*
Boundaries and Safety
In Boundaries and Safety, training needs were associated with medico-legal responsibilities, and strategies to
allow the CR practitioner to manage workloads and competing demands. There was also a need for training in
areas relating to professional disengagement within communities, and personal boundaries in CR service
delivery (see Table 24). These findings point to the increasing legal context of service provision, which clashes
with the poorly defined and nebulous nature of community work.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
125
Table 24: Boundaries and Safety Competency Items of Training Need
Item
Competency
6
7
10
11
12
13
Use negotiation and conflict resolution skills to resolve difficult situations
Understand the legal responsibilities that impact on practice
Understand medico-legal and duty of care issues when delegating tasks
Develop strategies to manage competing demands
Conduct structured and regular review of workload, case load and outcomes
Develop skills of Consumer disengagement and case closure, particularly in
small communities
15
Balance community needs with personal and service demands
Items
Over 50%
agreement
*
*
*
*
*
*
Items
Over 75%
agreement
*
Consumer Engagement
It is interesting to note, however, that Consumer Engagement was considered the area of least training need,
suggesting that CR practitioners were confident in their ability to engage Consumers. Specifically, only three
items required training. These items related to facilitating Consumers to identify goals and direct their own
rehabilitation (i.e., self-management behaviour) in addition to clarifying the expectations of CR between
stakeholders.
While practitioners were keen to enable Consumers to self-manage, they identified a lack of skill base around
discharge planning, Consumer-practitioner disengagement and the management of more complex cases. For
instance, according to the Interview data, there was a clear need for skills and knowledge that would enable
practitioners to handle difficult or complex situations relating to Consumers. Many practitioners felt
overwhelmed by multicultural differences, sensitive issues, disengaging from Consumers when one has
assumed such a pivotal role in their lives, maintaining practice boundaries in small communities, supporting
Consumers irrespective of their responses to rehabilitation, dealing with difficult interactions to produce positive
outcomes.
Table 25: Consumer Engagement Competency Items of Training Need
Item
7
8
11
Competency
Align the expectations of Consumers, professionals and services
Encourage Consumers to direct their rehabilitation process
Facilitate Consumers to identify and achieve their own goals
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
Items
Over 50%
agreement
*
*
*
Items
Over 75%
agreement
126
Facilitators of Education
127
What are the different perceptions of training and education issues?
What delivery format is appropriate for education and training?
What enablers will facilitate education and training?
.
This section of the report concerns the training issues and challenges that are important to address, the way in
which training can be delivered and the factors/solutions that might be found.
The first part of the section contains the analysis of training issues identified in the Interviews. These issues
were identified in response to questions about how to acquire competencies in CR, best and worst
experiences with training in the past, attendance at current training opportunities and general comments about
different types of training. These issues generally represent challenges or barriers that influence the success
of training or participation in training.
The second part of the section specifically addresses delivery format for training. In the survey, participants
were asked to indicate the methods of training they currently used and any comments about those methods.
In the Interviews, participants were asked about their preference for particular delivery methods and
experiences with these methods. These results are combined.
Finally, this section will identify some factors that were thought to facilitate attendance and engagement in
learning about CR in Queensland. Much of this data was derived from the Interviews, but participants who
responded to the survey were also provided with the opportunity to identify facilitators and solutions.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
127
Barriers to CR Training
Barriers to attending training were identified by almost all practitioners. For some practitioners, these barriers
were insurmountable and resulted in their failure to attend training of any kind. In contrast, some participants
recognised barriers, but indicated that part of their commitment to training involved circumventing these
barriers. In discussing the role of training in their professional lives, a few practitioners posed interesting
questions. They queried whether or not all CR competencies were “trainable”, particularly those that were
based on values and attitudes. When this question was posed to survey participants, the majority agreed, but
indicated that awareness can never be wasted. Thus, even if some CR competencies are not “trainable”, it was
considered necessary to continue training in these areas.
Some practitioners questioned the role of life experience in the ability to learn CR competencies. For instance,
an interesting query raised by a few practitioners was the likely impact of their own status and background. As
described by one practitioner, most rehabilitation practitioners were women from white middle-class
backgrounds and were, by definition, well-educated. Consequently, their capacity to easily assume the
perspective and experiences of Consumers was likely to be hindered, particularly when issues such as culture,
poverty or gender were implicated. Most practitioners who responded to this query in the survey concurred that
experience in life was essential, but that good preparation for the context of CR and realistic mentoring or
practicums would assist new practitioners. The value that should be placed on experienced CR practitioners
was confirmed.
Another query involved the purpose of training, in that it is generally believed to be a process for creating
experts. These practitioners noted that an equally significant purpose was to identify the fact that we are not
experts. Practitioners who responded to the survey query on this topic generally reported that attendance at
training for the purpose of general awareness should be encouraged. Often, practitioners have to demonstrate
how training will be directly relevant to their practice, but often it is awareness about other practices that is
required to improve their performance. Some practitioners even suggested that this industry should encourage
other practitioners (e.g., GPs, specialists, community members etc.) to attend general CR training to promote
awareness.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
128
Some practitioners questioned the fact that training was defined as something that should be delivered by an
expert practitioner or an academic when the real experts were Consumers. The opportunity to learn from
Consumers was often overlooked, and was only mentioned as a source of learning by a small number of
practitioners during their Interviews. However, when surveyed about methods of learning that were currently
used, only 5% reported never relying on input from Consumers. At least half of the practitioners reported that
they regularly consulted Consumers as a source of learning.
Issue/Challenge
Life experience
is essential
Can all CR skills
be trained?
Purpose of
training is not
always to
become an
expert
Consumers are a
source of
information
Examples to Illustrate Issue
x Students must learn to work with people from different cultures in challenging
circumstances -- most practitioners are white and well educated
x Life experience is the most important learning tool
x New graduates – preparation for rural placement is lacking – they don’t have the life skills
yet – it is not completely a matter of clinical education
x It is very difficult to impart some skills that are needed in CR – e.g., problem-solving skills,
negotiation, teamwork, networking
x Not without experience – new graduates lack experience implementing their base skills in
a wide variety of clinical settings - they may have the skills, but don’t feel they have the
experience to make them confident
x Training needs to be accessed NOT always to become an expert, but also to learn about
something in a basic way and just see how well they can do it. Training can be attended
just to see how much better an expert can do it – so that practitioners know when to refer
to an expert. Training facilitates the opportunity to learn about one’s own limits and when
to refer.
x Learning from Consumers themselves is often overlooked
Although there were many genuine barriers to training present in their environment, most practitioners focused
on five major barriers.
x The lack of an individual commitment to professional development and learning in some practitioners
x The lack of an organisational culture of staff development within their workplace and the industry
x The need for training to accommodate such a range of situational factors and circumstances
x The need for training to accommodate a range of levels of knowledge and styles of learning
x The fact that training attendance was often motivated by clinical dilemmas rather than CR practice.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
129
The majority of practitioners made some comment about the fact that attitude was the most profound barrier to
training among practitioners. Many practitioners noted that the need for a positive attitude to learning. Rather
than viewing learning as part of a professional discipline, they noticed that when practitioners were busy with
practical work, learning was usually their last priority. They noted that many practitioners lacked a proactive
approach to learning (i.e., identifying areas where they required development, seeking out opportunities to
learn, overcoming other obstacles if necessary, being willing to admit lack of knowledge and being assertive
about their needs).
Similarly, participants mentioned the fact that to stimulate individual learning attitudes among practitioners,
there was a need to develop organisational or workplace cultures that promoted learning, supported training
attendance, provided access to opportunities and valued the outcomes of training. A negative training culture
was a significant barrier to practitioners, although it was often not articulated publicly in the workplace. Many
practitioners commented on the need for services to be prepared to balance service delivery with education,
thus including education/training in the core business of practitioners.
In discussing the attendance of practitioners at training, it was noted that training must accommodate such a
diverse range of situational factors and circumstances. As a result, an appropriate program for all practitioners
would be difficult to implement. Shift rotations, rural and remote locations, work-life interactions were just some
of the factors that had to be considered in designing a training program. Further, it was noted that learning
styles differed dramatically across practitioners, leading to the need for different styles of delivery.
Perhaps the most interesting barrier that was mentioned by the majority of practitioners was the fact that actual
attendance at training was thought to be most often triggered by a clinical emergency or a dilemma (e.g.,
referral of an individual with a specific condition about which the practitioner was unfamiliar, a difficult challenge
in a discipline-specific area). They noted that training was usually attended because practitioners were seeking
clinical skills rather than community skills.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
130
Issue/Challenge
The lack of a
commitment to
learning
An
organisational
culture of staff
development
Training must
accommodate a
range of
situational
Examples to Illustrate
x It is hard to convince practitioners that training should be a priority – they are overloaded
with other things that are important
x Attitude towards learning is the most important quality – nothing is a waste of time – we
need to be proactive and seek out training options – how do we develop this attitude?
x Aim to change culture and attitudes towards training and provide incentives to engage
staff in learning
x Commitment and initiative to pursue training is important – some choose to pursue
training in their own time, but others just don’t have that interest
x Self-initiated learning – a proactive approach to learning is critical
x Practitioners need to be assertive about their training needs
x Clinicians are not always forthcoming in asking for help – they feel they should be able to
manage after completing their degree
x Practitioners of any experience level will come across situations they don’t know how to
handle – not just new graduates -- there will be a need for learning – the important issue
is that they must recognise the need and act upon it
x Need a flexible approach because learning is a lifelong skill and is ongoing – need an
everyday commitment to learning
x We should consider ourselves fortunate to be able to access training
x It is about continually going above and beyond their current role to advance our practice
– learning is an ongoing process
x It is important to have a work culture that supports and encourages staff to attend
training
x Training does not have to be a one-off formal event as there can be many forms of selfinitiated learning that are part of a learning culture – it needs to become second nature
and ingrained in the culture
x We need a culture of supporting and encouraging ongoing personal and professional
development for all staff
x Need to be prepared to close the service so the team can attend important training
x Employers must value an employee who seeks postgraduate qualifications – even if they
don’t pay for the person to do the study, they must find a way to value it
x Training should be part of the job – during work hours and week days – some people will
commit to training beyond work hours, but they should have the opportunity to integrate
learning within their workplace
x New graduates need support, not just training, especially in rural areas where they may
not have a team around them
x If there is no one to run the service, management will be reluctant to send their staff to
training
x Either through networking, finding evidence, seeking training…. This all comes down to
creating this culture that values ongoing self directed learning and openness to saying ‘I
don’t know, but I will find out’
x Training that can accommodate all methods of operating are difficult to design e.g.,
rotational positions, specific areas for some providers and general areas for other
providers, different backgrounds means different base-knowledge, time commitments
and work-life balance issues etc
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
131
factors and
circumstances
Training must
respond to many
different styles of
learning and
levels of
knowledge
Attendance at
training is often
motivated by
clinical dilemmas
x Need to offer a range of options – post-graduate or long-term study may not be
appropriate for all practitioners – short courses are important
x Circumstances of practitioners prevent use of innovative schemes such as scholarships
and bursaries (e.g., no relief or replacements, staff shortages, no travel funds, inability to
commit to long term study)
x Workshops must meet many different and preferred learning styles and levels of
knowledge
x A flexible approach to learning is necessary
x Have to consider different learning styles – adults learn in so many different ways
x It is difficult getting everyone who is at the same level – training cannot meet everyone’s
needs – The greatest challenge is to deliver training that is suitable to everyone in the
group
x Rural and metropolitan training needs will be very different – often they are the only
practitioner so have different demands on them
x It is challenging to run a complement of workshops for practitioners because their
disciplines differ markedly
x Clinical issues usually drive the need for attendance at training
x The need to develop knowledge about specific conditions will motivate people to attend
training and is most valued
x We need short courses in different conditions
x Education about specific conditions is essential – need to be able to call on that
information and education when it is relevant
Although these major themes appeared to dominate the views about barriers to training, several other themes
also emerged as being important to a large group of practitioners. These themes involved the role of
supervision and the impact of discipline specific frameworks on training, the implementation of training into
practice, the lack of CR-specific opportunities for training and knowledge of where to find such information and
the need for training to fit into a broader career path.
Interestingly, supervision was seen as a critical part of learning how to practice effectively but, at the same time,
was a significant barrier to CR. For most practitioners, mentors and supervisors were clinical rather than
community in their orientation. They tended to direct supervision requirements and experiences towards clinical
practice and were unable to appreciate the issues faced by CR practitioners. Often, supervisors were based in
hospitals and had never engaged in community work. Very few practitioners reported having had good
supervision experiences, and believed that supervision continued to have negative implications in clinical
practice (i.e., a punitive framework with the underlying message that a practitioner was deficient). The following
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
132
quote is indicative of how leadership and supervision are capable of perpetuating an unhelpful context for CR
rather than developing practitioners who can deliver CR in a way that brings about optimal outcomes:
…all of the supervision of community based staff comes from managers in the hospitals who don’t understand
even things like primary health care, they don’t understand. And they’re supervising clinicians working in a
community setting. It’s creating a lot of tension because we’re saying you don’t even understand our
Consumers let alone CR, and they’re trying to dictate policies of how the community operates. So I guess
everyone’s being sucked back into the hospital.
A major issue faced by practitioners was the fact that CR training opportunities were not readily available or
easy to locate. The comments made by practitioners indicated that they were seeking courses that were clearly
labelled as CR. In reality, however, courses and training programs were available in areas such as community
development, valuing Consumer perspectives, motivational Interviewing and so forth. However, these courses
were often delivered in non-clinical contexts and were not considered relevant by practitioners or were not
readily accessible to them. Thus, this issue appeared to be a multi-faceted barrier (i.e., both the relative
absence of CR training compared to acute training and the knowledge among practitioners of where to look for
relevant training opportunities).
An interesting concern among many practitioners was that training did not necessarily result in implementation.
They believed that “good” training should have inbuilt opportunities for implementation, or should be part of a
larger program designed to ensure implementation. Some felt that any access to training should be associated
with an automatic opportunity to practice that skill in an applied setting or an assessment of the skill in practice.
Although this was not a dominant theme, it recurred in many different forms and was common to a large
number of practitioners. It was a regular qualifier during any discussions of training.
Finally, practitioners commented on the fact that training should fit into a broader career path – it should be part
of a career structure that would enable them to progress or achieve desired positions and recognition. Some
practitioners noted that although training was an important part of a professional orientation to CR, there also
had to be recognition of the fact that practitioners were driven by their own career needs.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
133
Issue/Challenge
Examples to Illustrate Issue
Commitment to
supervision as a
means of
learning
x
x
Issues created
by Discipline
boundaries
x
x
x
x
x
Making CR a
learning priority
over other
learning
x
x
x
Lack of CR
specific learning
opportunities
x
x
x
x
x
Locating
opportunities for
learning is
difficult
Implementation
is problematic –
does learning
occur unless it is
applied?
x
x
x
x
x
x
Need CR practitioners to register as mentors and supervisors for new practitioners
Supervision is often viewed from a punitive angle rather than in a positive light as an
essential part of learning
Practical hands on experience under good supervision in various settings
Supervision is something that is very poorly done and probably few practitioners have had
very much good supervision
Currently supervised by clinical experts rather than CR experts – lack of formal mentoring
or supervision that is relevant to CR
Managers and supervisors who are not in CR often rate CR practitioners on their clinical
skills (e.g., splinting, bandaging, etc.) when these are not the most critical skills to CR –
CR skills are viewed as secondary and inferior
Different systems of supervision and support across disciplines leads to ad hoc training
and mentoring
Practitioners are still viewed as a specific discipline professional working in a CR team
rather than as a CR practitioner who has a background in a specific discipline – this
attitude impacts on training opportunities, resources for training, supervision etc
Rehabilitation specific skills are needed on top of the discipline specific knowledge of
rehabilitation – knowledge of the whole rehabilitation process and a big picture
perspective
Practitioners are afraid that they will lose their specialist skills that they have trained for
over the years – they still need opportunities to keep them up-to-date, so generalist
training may never be their priority
Conferences are a good option for learning – but often no funding is available – and there
are few conferences that focus totally on community issues
There are just not enough training opportunities, particularly in community areas – getting
better as more funding is put into this area, but very limited
Training is not offered – practitioners need to be skilled at seeking out opportunities,
knowing what they need and finding ways of attending – networks and memberships help
practitioners to identify training opportunities
It is difficult to get certain training topics off the ground – hard to get presenters with
expertise
It is very difficult to get quality presenters despite going to great lengths – presenters who
are well prepared, organised and have good presentation style as well as providing
comprehensive notes – they are few and far between. Facilitators must encourage
participants rather than scrutinize them
Streamlined process for locating and applying for scholarships and research funding
Have to be able to ask for training opportunities
Need to be proactive because learning opportunities are rarely offered
Post-training is a bigger issue than training – how can we review and monitor
implementation following training?
Actually using the information is most difficult – not just learning skills, but developing
skills
Training must be followed by practice or it is wasted
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
134
x
Training must fit
into a career path
x
x
x
x
Learning needs to
be planned and
individualised
x
x
x
x
Mandatory training requirements might help – yearly assessment of competencies that
are basic to practice
Need to take a broad view of career progression and formal advancement through
learning - things like graduate certificates and masters degrees
There must be recognition of qualifications through pay advancement, especially for
Aboriginal Health Workers and Therapy Assistants
We have to create certificate courses in various areas so people can learn specific skills
and have a career path
The professional advancement scheme is useful – people need to be able to progress as
a result of training or increased knowledge
Trial and error is a common way of learning in CR. Need to develop a learning plan with
each practitioner in CR, focusing on their unique competencies and interests and linking
these with learning opportunities
Practitioners need to identify their education/learning needs and then match the available
opportunities to their identified need
We need to develop a profile of the training needs of a service or a profession or some
other category and then tailor the training to meet their needs
Training need to be justified and it must align with priorities for health services or
programmes
In discussing barriers to training, a number of other issues arose that related to the accessibility of information,
and the resources or physical supports that were required to access training. These issues were relatively
predictable, and focused on direct funding (i.e., travel, accommodation, registration), indirect funding (i.e.,
backfill during absences), access to local knowledge bases (e.g., resource directories, contact lists, local
protocols), equitable access to training across disciplines and levels of experience (especially in relation to
support personnel who often felt as though they were excluded from training opportunities) and a source of
quick information to address immediate needs for Consumers and practitioners. Databases of useful
information were mentioned several times in the Interviews.
Issue/Challenge
Knowledge must
be localised
Information must
be available
quickly and
easily
x
x
x
x
x
Examples to Illustrate Issue
Awareness and use of local community resources – new graduates don’t know who is
available to help them
Learning is much better when it happens in their own context
Information must be available quickly and easily - Manuals are very useful and quick to
access whereas videos are too long – CDs and DVDs are useful if you can access the
information quickly, internet is not easy to access for everyone, online tutorials are too
time consuming and computer access can be problematic. Journal Club was a failure
because of the time it consumed – a good idea but not likely to be supported
Lectures should be brief or broken up into small talks
Clinicians get overwhelmed with the amount of information that is available
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
135
Funding barriers
to training
Training
opportunities
should be open
to all
practitioners
Access to useful
databases of
evidence will
facilitate learning
x Materials must be available and accessible easily so practitioners don’t panic if they don’t
know something – they know they can access things quickly if they need to
x Keep everything brief – too much talking puts you to sleep – you have to keep it
interesting
x Lack of funding to attend training that is available – and many can’t or won’t self-fund
x Most training opportunities are in Brisbane or in major regional towns – cost is a barrier
x Cost can be prohibitive in relation to university studies with HECS and university fees
x If there is no one to run the service, management will be reluctant to send their staff to
training
x People will travel to workshops if they are relevant and there are some funding sources
(not a lot) – it is possible, so we have to attract them to training
x Equality is important in training opportunities – TAs should be offered as many
opportunities as practitioners
x Sometimes, training is about learning what others do rather than what you should do
x What is the evidence base in relation to specific treatment issues – i.e., home versus
centre based treatment, so we can make sound resource allocation decisions
x Develop a website for CR practitioners to access – to ensure all are on the same
framework
x Research training is important also, not only practice skills – library sessions and evidencebased practice introductions
x Practitioners need to be trained to access evidence as it is difficult to narrow down complex
searches – practitioners get overwhelmed with the amount of information
Facilitators of Training
The challenges identified above were re-presented to the participants who completed the survey. They were
asked to identify any significant facilitators that would assist them to address these issues. Interestingly, the
only barrier that was challenged by the majority of practitioners was the suggestion that CR needed to become
a priority for learning over clinical issues. Practitioners noted that clinical issues would probably always motivate
training attendance and that the training industry should capitalise on this fact, by integrating CR-specific
modules into clinical training programs. Instead of becoming a higher learning priority, practitioners suggested
that CR should be increased as a focus for all relevant training to ensure that all practitioners associated with
disability and rehabilitation gained an understanding of CR. Other practitioners commented on the fact that
demand for CR-specific training would naturally increase as a result of increases in the prevalence of CR
workers and the acceptability of non-medical models of practice.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
136
The facilitators identified by practitioners were generally associated with increases in the profile of CR as a
legitimate model of practice and formal recognition of the need for training to support practice. These facilitators
could be summarised into eight major categories. These categories focused on the supportiveness of the broad
policy environment, specific workplace practices, the role of Consumers and mentoring, increasing the
accessibility of training information and opportunities, the funding allocation process and a coherent framework
for CR training and development. Specific points associated with each of these categories are outlined below:
Create an environment that is supportive of CR and practitioners’ training needs
x Policy changes are required to incorporate training into workloads and recognise CR
x Ensure learning opportunities contain an element of cultural change so long term benefits accrue to CR
x Marketing of CR to promote its profile
x Interdisciplinary training opportunities that transcend discipline boundaries and encourage collaboration
x Promote awareness of CR in supervisors and managers so they support practitioners appropriately
Incorporate learning objectives into CR workplaces
x Promotion of learning and training in CR by line managers
x Permission in workplaces to allocate time to learning
x Inclusion of learning in role description and job contract for CR practitioners
x Reduced Consumer load to accommodate learning objectives into workload
x Participation in professional development procedures that incorporate learning goals
x Promotion of supportive practices in workplaces to ensure collegial learning
Promote the ability of Consumers to actively educate practitioners
x Involve Consumers in training
x Educate Consumers about their “right” to train practitioners
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
137
Actively promote mentoring in CR
x Increase the number of mentors in CR and develop a register to formalise the process
x Improve attitudes towards supervision and its purpose, provide training in supervision skills
x Provide time to prepare for mentoring/supervision as well as time to attend
Develop a formal and coherent framework for CR training and development
x Develop a tiered training program that practitioners can enter at their relevant level
x Provide a consistent framework for training programs about CR to ensure compatibility across courses
x Include CR concepts in undergraduate training programs, but also offer post-graduate subjects/courses
Ensure access to information about training opportunities
x An accessible and up-to-date information network, newsletter or database of training opportunities
x Information collation to produce an annual training timetable in advance
x Extensive marketing of training to all organisations and registered practitioners
Increase accessibility to training through local and flexible options based on adult learning principles
x Train local trainers and mentors and increase access to or knowledge of local training venues
x Incorporate adult learning principles into any training opportunities
x Provide flexible schedules to accommodate active practitioners
x Recognise that not all practitioners and organisations have access to internet or email
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
138
Examine management and allocation of funding sources and ability of practitioners to apply
x Centralised funding source to ensure priority training areas are addressed
x Allocation of specified professional development funds to each staff member
x Increase scholarship or professional development funds to include issues such as backfill for positions
x Be responsive to situations where leave for training is difficult due to resource or staffing issues
x Assistance to apply for professional development opportunities and innovative schemes
Delivery Methods
Practitioners who completed the survey indicated the frequency with which they used a range of methods to
gain information when necessary. Although these responses are linked to the types of training that are currently
available to practitioners, their responses indicate those methods that are favoured and familiar sources of
information. As shown in the Table 26 below, no one method of training was favoured by the majority of
participants. In fact, the findings indicated that most practitioners used a variety of methods to gather
information when they needed to do so. Nevertheless, over 20% of the practitioners turned to online
documentation or experts when they required information, indicating that these sources may be worth
improving. Almost 80% of practitioners regularly attended local training seminars, team-based learning in their
workplaces and expert workshops.
Training opportunities that facilitated team work, networking and collaborative learning among CR practitioners
(e.g., training seminars at the workplace, team-based learning, networks with other practitioners, workshops
with experts and conferences) were generally the most commonly used methods of training. These training
events offer several methods of learning (e.g., experts, collaboration, support, printed material, experience
etc.). Interestingly, Consumer input was recognised by some practitioners as a useful method of CR learning,
which may indicate the need to formalise access to Consumers in this way.
Several training methods were used variably across practitioners (e.g., videos, supervision, mentoring,
development plans, practicum or placements and university subjects or courses). These methods tended to
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
139
involve a more formal learning experience, but may also have been less available to some practitioners.
Further, these methods tend to require significantly more time commitment and may not be used regularly.
However, this finding has important implications regarding the future design and delivery of tertiary education in
Queensland as it clearly needs to become more relevant to CR practitioners. It may be constructive to review
current university training courses, along with consideration of alternative modes of university training if the
university sector is to remain relevant in CR. The provision of on-line short courses, credit reimbursement for
field training, supervised short-courses are non-traditional ways of learning through universities, but are
necessary in order to increase enrolments from busy practitioners, and formalise the skill base of CR
practitioners. It may also be necessary to examine the role of mentoring and supervision in CR practice, as it
does not appear to be occurring consistently at present.
Table 26: Summary of Currently Used Training Methods
Training Method
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Books
Printed documentation or manuals
On-line documents and articles
On-line tutorials
A database, library or clearing house of evidence
Videos
Training seminars at the workplace
Workshops with experts
Team-based learning
A training newsletter or website
Formal supervision
Mentoring on the job
Training development plan
Networks with other practitioners
Experiential practicum, placements or exchanges
Email lists and on-line discussion groups
Videoconferencing
Teleconferencing
University subjects or courses
Conferences
Input from Consumers
Frequency of Use
Every time I
need info.
0%
0%
18%
13%
15%
0%
13%
21%
13%
5%
0%
3%
3%
10%
5%
5%
8%
3%
3%
10%
10%
Most
times
25%
44%
38%
28%
36%
31%
54%
49%
44%
31%
31%
42%
46%
62%
31%
26%
21%
21%
23%
49%
41%
Sometimes
Rarely
59%
46%
41%
28%
26%
44%
33%
28%
38%
39%
36%
38%
31%
26%
26%
44%
41%
44%
31%
39%
46%
15%
10%
3%
30%
21%
26%
0%
3%
3%
26%
33%
18%
21%
3%
36%
26%
31%
33%
44%
3%
3%
NOTE: Not all rows equal 100%.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
140
Although the popularity of web-based technology is generally increasing as a method of disseminating
evidence-based practice within the health sciences, it is notable that website training was a least used method
for approximately 60% to 70% of the practitioners (e.g., online discussions, online tutorials, training websites).
Other technology-based methods (e.g., videoconferencing, teleconferencing, videos) were also not regularly
used. Books and printed materials were infrequently used by over 80% of the practitioners, possibly due to the
limited number of publications on the topic of CR. However, on-line documents and articles were highly
regarded as training tools. Similarly, databases of evidence were used by over 70% of the practitioners, even
though only a limited number of such repositories are available. This latter finding suggests that targeted,
accessible and focussed on-line information has a legitimate place in CR training. It also highlights the need for
websites that are specific to CR topics, regularly updated, and widely marketed to reach the target audiences,
particularly those in rural and remote locations who require fast and efficient communication.
In the Interviews, practitioners provided some discussion about the issues associated with different methods of
delivering training. The most common point raised by practitioners in this area involved the need to combine
several methods, notably, videos/films with written material and practical workshops with networking
opportunities. Almost every mention of video material was combined with the need for associated written
manuals or learning summaries for later use and to assist with implementation on the job. Similarly, learning
programs were regarded as being meaningless if they were not accompanied by hands-on instruction or
networking opportunities.
Preferred Methods
Examples to Illustrate
Videos and written material,
within a network session –
a necessary combination
x [Professional Body] provides an evening video viewing followed by a
teleconference workshop with training tasks and expert panel discussions with
question and answers – the combination is the key
x Video and manual is a very useful combination because it shows techniques,
but also provides further information
x Videos are most useful for new CR practitioners without much experience, but
reading material is useful – need assistance to locate appropriate reading
material (search engines and databases)
x Videos and training films are preferred, if they are paired with written material
and practical exercises. Reading material and manuals aid the learning process
– even seminars must be accompanied by written material
x Use of different medium throughout is important as it keeps things interesting
and allows for different learning styles
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
141
x Online is good because it is a form of reading material that can be printed and
kept as a reference
x Internet modules can be downloaded
x Written materials are useful for background information, but not as useful if you
need to keep up with changing pace of knowledge
x Videos depend on the content – some aspects of practice (the feel/touch/three
dimensions) are hard to convey on video
Preferred Methods
Examples to Illustrate
Hands-on training
combined with group
networking is critical
x All learning should be accompanied by some practical exercises as soon as
possible
x Group processes and discussions are important to the learning
x Training must have strong practical implications – university courses often lack
practical and real work application, training seminars are more practical and
provide networking opportunities
x The university training is very high quality, but the amount of clinical placement
they can offer, the funding and time constraints limit the practical component.
However, university lecturers are well received and that credibility is important
x Long conferences without practical application are not useful, but conferences
are still important because of the networks
x Student placements are a great way to learn – cross-discipline placements that
enable everyone to gain from the different knowledge-bases and networks
In addition to the notion of combined methods, four delivery modes were mentioned most often. These
included:
x On the job training with good mentoring
x Team-based learning in the workplace
x Exposure to multiple environments and workplaces
x Networks of experts sharing information
Most commonly, practitioners indicated a strong preference for learning that occurred on the job under good
mentorship. Models such as coaching, mentoring and shadowing were mentioned regularly, in that these
models provided the opportunity to practice with supportive instruction and feedback. Role-plays were not
considered to be useful or easy and practitioners concluded that new learning had to be applied in real
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
142
situations. They commented that this type of learning did not replace an undergraduate education and
professional development seminars, but was an essential extension of theory-based learning.
In developing this “on-the-job” model further, some practitioners discussed the need for team-based learning
within the actual work environment. They commented that many problems and issues faced by practitioners
were unique to their particular setting or context and could only be solved with the team. Further, the support of
a team enhanced learning capability and reinforced the process of application.
Although the specific workplace was the most valuable site for learning, practitioners commented that it was
critical for new practitioners to experience multiple worksites and models of rehabilitation to broaden their
knowledge-base and allow them to distinguish between different practices. Even for experienced practitioners,
it was repeatedly noted that rotational placements would enable them to retain a range of skills rather than
become specialised in one area.
In addition to locally derived networks, placements and mentoring in the workplace, practitioners acknowledged
the essential role of a range of experts. They believed that practitioners carried a responsibility to network
effectively with each other to inform the discipline and transfer knowledge. Although networking was considered
to be critical by many practitioners, videoconferencing was not universally accepted as the appropriate method
of doing so. Some practitioners had enjoyed videoconferencing experiences, but many had found it to be
unnatural, uncomfortable and “difficult to get the dynamics right”. They also commented that technical issues
made videoconferencing difficult to use. Nevertheless, it remained a “good idea” that may improve with time
and practice.
Preferred Methods
Examples to Illustrate
On the job – strategies to
enhance experiential
learning
x On the job training is the best kind – you retain skills when you see someone
doing it or have to apply it yourself
x Experiential learning on the job – particularly relevant to new practitioners
x Experiential learning builds quickly on the university theory base – university
background provides a platform for learning in practice
x Hands on experience rather than just courses – university is just the basis – the
real learning begins once practitioners start working
x Experiential hands on supervised practice is the best
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
143
A collaborative team
learning environment based
in the workplace
Exposure to different
environments is a source of
learning
x Practical hands on experience under good supervision in various settings
x Spending a day off line with an experienced practitioner, shadowing, coaching,
mentoring
x Recognition of different learning styles is necessary – but sometimes
geographic location (or other circumstances) means that practitioners have to
‘learn’ a new learning style out of necessity
x Shadowing, mentoring, coaching – spend a day with an experienced
practitioner – an opportunity to observe is always important
x Learning from colleagues is important – need to have opportunities to learn
from each other and gain skills from working together or sharing
x Team in-service training is so useful
x Training developed by the team is the best – it is relevant to the local issues
and accommodates the different needs of team members
x Practitioners need to learn from co-workers by asking questions – they also
need to be prepared to impart knowledge openly
x In house training is important – a good orientation and ongoing supervision
within the team
x Feedback from other practitioners is relevant as a learning tool, especially when
less experienced – it is often not provided unless requested
x Need to foster peer learning as part of team building
x Teams can work together – give presentations to each other – this builds
respect and knowledge within the team. It is the Team Leader’s responsibility to
foster this type of collegial learning
x If practitioners go off to a workshop, they must understand that they will always
have to present what they’ve learnt to their peers
x We can support each other, encourage each other, share travel and knowledge
x Exposure to a range of different environments is probably the best training
experience – rural placements, hospital placements, rotating positions, field
exchanges, etc
x Experiential learning, but in a range of contexts
x Rotations between community and acute will assist with education – foster
sharing of knowledge and respect for each others roles
x Exposure to different disciplines and the interrelationships facilitates valuable
understanding
x Learning in Nursing Home context is a valuable step towards community work –
provides relationship skills and people skills more than in the acute setting
x Life experience is the best teacher
x Experience in the hospital provides a good base in different health conditions
so practitioners do not feel overwhelmed when they reach the community
x Practical hands on experience under good supervision in various settings
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
144
Recognition of the role of
experts and the need to
network with many types of
people to learn
x Pharmacists are a valuable source of information and are accessible
x Visiting experts
x Practitioners must self-initiate learning by tapping into experts, seeking
information from important mentors, talking on the phone, email
x Training should be followed by ongoing links with others in the field to access
for support in practice
x Creating links and networks is critical to ongoing learning
x Networks are an essential part of learning
x Maximise attendance at workshops by having an expert speak
x Consumers are experts also
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
145
Support Personnel
146
What are the current and potential future roles of support personnel in CR?
This section of the report will describe the data pertaining to support personnel. The meaning of “support
personnel” will be defined and the usual job descriptions/roles associated with this label will be identified. This
section will then review the types of roles discussed by CR practitioners and the issues they faced when
working with support personnel.
The first part of this section will outline the types of support personnel that were used by CR practitioners or
might be required in future to facilitate their work in CR. The data that informed this analysis was Interview
data from practitioners in response to questions about the types of people and skills/tasks that might be
helpful to CR. In the second part of this section, issues and challenges that have been experienced in working
with support personnel will be described.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
146
Although the topic of support personnel in CR was only a minor focus of the current audit, it emerged as a
fundamental issue that has major implications for workforce design. An in-depth exploration of this issue is
beyond the scope of this study, as there are many different models depicting the use of support personnel in
CR that warrant comparison and examination in greater detail. However, the data revealed a number of key
issues and questions about the use of support personnel in CR that provide a useful platform to inform current
dialogue and future investigation.
Practitioners tended to express fairly narrow views regarding the support personnel roles that were relevant and
appropriate to their CR work. Their responses also tended to be associated with their discipline background.
For instance, Occupational Therapists, Physiotherapists and Speech Pathologists identified Therapy
Assistants/Allied Health Assistants, and Administration Officers as the current and future roles that were most
beneficial to their CR, while Nurses identified Enrolled Nurses and Personal Care Attendants as the most
beneficial. However, a number of practitioners acknowledged that there was a range of other resources
available to them. Overall, the data revealed six general categories of support personnel roles that were
considered relevant to CR work:
Type of Support Personnel Currently Utilised in CR
x
x
x
x
x
x
Technical support for practitioners
Administrative and practical help for practitioners
Lifestyle support for Consumers (physical, practical and social)
Aboriginal and Torres Strait Islander Health Worker
Natural supports in the Consumer’s environment
Community advocates and support groups/organisations
In addition to these more standard roles, a ‘wish-list’ emerged that included some well thought-out and specific
roles, as well as some fairly nebulous ideas about what might be beneficial for CR in future. These roles might
not necessarily be distinct roles in their own right; rather they might be facets of activity that could be integrated
into the responsibilities of an existing or newly developed support role.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
147
‘Wish-list” of Types of Support Personnel For Future Consideration
x
x
x
x
x
x
x
x
A crew to repair and manage equipment
Recreation Officers
Exercise Physiology support roles
A resource person to compile up-to-date information, prepare educational material for presentations
A facilitator of community access and social involvement
Practical support to help people without family to run errands
A Coordinator of Services or liaison person
A Cultural Translator or Interpreter in the same way as ATSIHW act as a link
x
A health promotion role
The support personnel roles described within this report emerged directly from the data so is unlikely to
represent an exhaustive list of the full range of support personnel roles available in the community. Despite the
fact that a number of support personnel roles emerged from the data as being potentially important to CR
outcomes and processes, there was minimal evidence of any strong links or collaboration between them. The
tables below present a brief description of the six main types of support personnel roles practitioners described
as being relevant to their CR work. The Therapy Assistant or Allied Health Assistant (TA/AHA) role was the
most common support personnel role described by practitioners and is, therefore, described in greater detail
than other roles.
Technical Support for Practitioners
x Therapy Assistants or
Allied Health Assistants
(TA/AHA)
x Physio Aides (PA)
x Enrolled Nurses (EN)
Therapy Assistants/Allied Health Assistants and Physio Aides provided technical
support for practitioners. These roles were the most commonly mentioned sources
of support for Physiotherapists, Occupational Therapists and Speech Pathologists.
Enrolled Nurses were the most commonly mentioned source of technical support for
Nurses and were often responsible for medication management, injections, wound
care, etc. While EN often worked autonomously in the community, TA/AHA and PA
tended to be centre-based and work under the direct supervision of a practitioner.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
148
Administration and Practical Support for the Practitioner
x Administration
x Equipment Management
Administration and practical support for practitioners was a commonly mentioned
source of support that was currently accessed by some, and highly regarded and
sought after by others in their CR work. Practitioners identified administration support
as “crucial” as they required assistance with arranging appointments, filing,
photocopying, booking travel, etc. In the absence of formal administration support,
TA/AHA often took on these tasks, as well as that of equipment management.
Managing equipment was an extremely time consuming task for practitioners, and
was considered a distraction from their clinical work. Support to manage equipment
(e.g., ordering, following-up, labelling, storing, delivering, cleaning), was highly
valued.
Aboriginal and Torres Strait Islander Health Workers (ATSIHW)
ATSIHW play a vital role in CR. Most ATSIHW did not see themselves as support personnel, as there were many examples
of how practitioners worked under their direction when accessing Indigenous communities. ATSIHW were expert cultural
brokers/educators. Practitioners who worked with Indigenous communities, particularly in rural and remote areas, relied
heavily on ATSIHW as a source of support. Engaging ATSIHW as support personnel in CR took different forms to suit the
needs and resources of each community. In Queensland, South Sea Islanders also fill ATSIHW positions.
Lifestyle Support (physical and social) for Consumers
Lifestyle support for Consumers encompassed a range of support personnel roles,
some with very different foci. These roles tended to be based outside of the health
system, often in the disability system. Provision of this type of support usually
occurred in the Consumer’s home environment and often had a physical and
Personal Care Attendants (PCA)
practical focus, such as the provision of hygiene care, domestic chores, exercise
Home and Community Care programs, and assistance with activities of daily living. Lifestyle support such as that
workers
offered by PCA was driven by the Consumer’s individual needs and preferences.
Consumer choice prevailed and the main role of the PCA was to provide physical
Disability Support Workers
and practical assistance as requested, within a clear scope of practice. The issue of
Aged Care Workers
boundaries was raised, particularly as the nature of the work was often intense -Community Access Workers
working with someone in their personal space who might require support with very
personal tasks required sensitivity and decorum. Support to assist Consumers to
Respite workers
participate more fully in their community was described as a “major gap”, despite the
Diversional Therapists
fact that many “haven’t truly integrated into the community and they are living in
Masseurs
isolation”. However, some non-profit CR providers employed innovative approaches
Assistant in Nursing (AIN)
to support personnel in CR. These organisations tended to define the role of support
personnel more broadly than just therapy, practical tasks or administration, and
focussed more on social support, community participation and meaningful activities
that could be linked back to rehabilitation goals. Lifestyle support was likely to be
long-term and did not necessarily have an end point, in contrast to the more therapy
focussed support personnel roles that had the main aim of eventually disengaging
from Consumer service provision.
Specific roles mentioned in the
data:
x
x
x
x
x
x
x
x
x
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
149
Community Advocacy and Supports
Including, but not limited to:
x Disease specific associations
x Advocacy organisations
x Health Promotion Officers
x Cultural Translators
x Support groups and
organisations
Community advocacy and supports were under-utilised sources of support for most
CR practitioners. Some practitioners recognised these resources were important as
they actually prepare the community to be more open to CR activities through
awareness raising, engagement, education, advocacy, etc… Thus, these roles
supported CR in a more global sense.
Natural Supports
x Volunteers
x Friends
x Family
x Neighbours
x Interested community members
x Church congregations
x Social groups
Laypersons/community members were seen as ideally placed, particularly in
rural/remote areas, to provide physical or emotional support to help the Consumer,
Carer, and family during their rehabilitation process. Provided with training to do
basic activities and implement specific management strategies, laypersons were
seen as playing a potentially critical role in assisting Consumers to transfer what they
learned in a therapy session into their daily life. Training family members or local
community members to carry on with programs in the interim between practitioner
visits was vital for visiting teams in rural and remote areas, and was seen as having
merit in any context. However, practitioners recognised that Carers or family
members were overloaded already, and some were hesitant to utilise them as
support personnel in CR.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
150
Therapy Assistant (TA) and Allied Health Assistant (AHA)
The TA/AHA Role: Summary points
x Some practitioners viewed the TA/AHA role in community with trepidation, being concerned about the legalities
of supervising an assistant. Supervision of TA/AHA seen as an extra role for practitioners, requiring training
and support.
x The main benefit of TA/AHAs was to practitioners and the health system. The benefits for Consumers were
generally described as a secondary consequence.
x An emerging role in community might involve working with Consumers in their homes, assisting with treatment
(e.g., activities of daily living, exercise programs, supporting them to implement strategies as prescribed by
practitioners) as well as supporting Consumers to participate in the community or therapeutic activities.
x TA/AHAs have potential to be particularly useful in rural and remote areas where Consumers might only see a
visiting CR practitioner infrequently. Rural and remote practitioners appeared more comfortable with the idea of
support personnel working autonomously, as they simply had no other choice but to rely on their assistance.
x Clear role descriptions, boundaries and scope of practice are required to minimise risk and ensure no overlap
with practitioners’ role and with Lifestyle Support Workers in the community.
x Use of TA/AHA for administration and equipment management was contentious, though common as a result of
the absence of formal administration support for many CR practitioners.
x Hospital or centre-based models of operationalising the TA/AHA role are more clearly developed and have
been transposed to the community without consideration of the impact of this different context.
x New models of employing TA/AHA in a community context are required, particularly given the debate around
supervision requirements (i.e., some practitioners argue for constant supervision, but a community-based
model, TA/AHAs would require more autonomy).
x Appropriate training and education required – a range of choices must be available, both formal and informal.
(See training and education section below)
According to participants, the rise in popularity of the TA/AHA role was a response to current and future
workforce demands -- “[AHAs play an] increasingly important role, because we’re not going to have the Allied
Healthstaff in our workforce to actually do a lot of hands on… there is just not going to be enough people to
support the workforce”. Indeed, participants commented that “rather than putting more therapists into
[rural/remote areas, we need]… people to support the therapists’ role”. However, some practitioners expressed
comments characterised by trepidation and curiosity, as they had minimal previous exposure to TA/AHA, other
than in a hospital setting, and queried how they would be utilised in community. “It does work in hospital. I
haven’t seen it work in community”. These practitioners were open to the idea of working with TA/AHA, but
argued for stringent guidelines for their scope of practice in order to ensure no overlap of roles with the
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
151
practitioners. Clear role descriptions and boundaries, direct supervision at all times, and adequate training and
education were considered vital.
According to participants who did have experience working with TA/AHA, their main benefit was to practitioners
and the health system. The benefits for Consumers were generally described as a secondary consequence.
Participants commented frequently on the benefits that practitioners gained through accessing TA/AHA support
– “they reduce stress on therapists by taking on some tasks”, “when I was the only OT here without a TA that
sort of stuff does weigh you down and it does take up a lot of time. And then it does free up your clinical time”.
Not surprisingly, most practitioners valued the contribution of various support personnel roles in their CR work,
describing them as “fantastic”, “very valuable”. Furthermore, some indicated that the employment of TA/AHA
reduced costs for the State Government – “It would save a lot of money for QH and save a lot of therapists
stress if they had someone to support them”.
A few practitioners noted how “an extra set of hands” to support practitioners benefited Consumers. Support
personnel were not seen as being limited by the same time constraints as practitioners, and as such, had the
luxury of not having to rush Consumers -- “it’s just taking the time, you can’t rush people who are disabled in
any way shape or form, you have to have to patience”.
“….she’s [TA] got more time [than practitioners do] and she’s very personable. She’s quite happy to sit
with someone for quite a long time. I’m happy to do it but I get a bit frustrated now and then because of
time constraints. That helps because she’s not always in that hurry that we might be and her personality is
quite laid back”.
However, most statements made by practitioners in relation to support personnel focussed on the value of the
role as a way of freeing up practitioners’ time, enabling them to focus more on their clinical role, and avoid
being subjected to the constant, mundane and repetitive tasks that characterised many rehabilitation activities.
“[SP] can take on time consuming tasks”; “the problem with any sort of rehabilitation service is the fact that
[the Consumer] … needs to be practicing and doing that task over and over again. And there comes a point
where in that practice you certainly don’t need a qualified person to be supervising it”; “I get the assistant to
do a lot of prep work for different things and photocopying and assisting the treatment. I use the assistants
a lot …they're fantastic”.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
152
Practitioners indicated that they typically had limited access to TA/AHA support. It was clear that they were
“spread thinly” and typically supported multiple practitioners. In several cases, practitioners described having no
or minimal access to support personnel in their current role, although some had previous exposure. Some
practitioners believed that such support was not common in Queensland – “We don’t seem to have a lot of TAs
up here. Down south they're a lot more common”. The potential benefits of accessing support personnel were
clear to these practitioners who viewed them as providing a general support network for CR, which was
particularly important in rural and remote areas – “it just means, especially in small areas, you’re not so much
working on your own, you have a general support network”.
There was some discussion about what type of background experience that provides a useful foundation for the
TA/AHA role. One participant believed that education provided a solid background for the TA/AHA role as
teachers were familiar with the process of grading tasks up or down according to the Consumer’s level. They
were also likely to support Consumers in self-directed learning. In contrast to this model, most TA/AHAs who
were currently involved in CR work had vast experience in the hospital context. Although clearly not exhaustive,
some of the competencies that practitioners believed TA/AHAs required included: workplace management and
prioritisation skills, facilitating Consumer implementation of treatment strategies, developing rapport with
Consumers, administration skills, networking skills, ‘all around skills’ in order to work with practitioners from
different disciplines, encouragement skills, building rapport, acknowledging improvements.
The TA/AHA role generally involved carrying out the direct instructions of the CR practitioners they supported -“So the physio and the OT do the actual assessments, and they’ve got the training and then they develop a
care plan, so to speak, and then the TAs actually follow through and provide feedback”. In fact, most TA/AHAs
supported multidisciplinary teams, and as such provided support to, and followed the instructions of, a variety of
practitioners – “I think one support person could actually have input from a number of different therapists”. The
role of TA/AHA was not one of innovation, autonomy and control, rather, their role is to carry out treatment
plans and therapy regimes that have been developed by practitioners.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
153
According to practitioners, the TA/AHA role involved a combination of tasks loosely categorised as: 1)
administrative, 2) practical, 3) equipment management, and 4) direct work with Consumers (see Table 27
below).
Table 27: Tasks usually conducted by TA/AHAs
Practical tasks
Setting up for groups, transporting Consumers
Equipment management
Organising, ordering, stocking, cleaning, labelling and follow-up of equipment
Administration tasks
Photocopying, filing, arranging appointments with Consumers, answering
telephones, etc…
Direct work with
Consumers
Carry-on treatment or therapy that is developed by practitioner following
assessment; assisting Consumers and practitioners during treatment;
supervising Consumers’ therapeutic activities – such as exercises (e.g.,
physical, language etc), use of equipment; warming up groups
In the absence of formal administration support, TA/AHA were often utilised to fill this gap. One participant
recognised this use of the TA/AHA role as “controversial”, but was unapologetic as the need for administration
and practical support was desperate. Only one participant challenged this practice outright, noting that the
employment of TA/AHA for administrative tasks and equipment maintenance was “a waste of potential”. This
practitioner was appalled at the “dumbing down” of the role rather than utilising and expanding on its potential.
According to this participant, TA/AHAs should always be working directly with Consumers – “I hate to see TAs
photocopying … or typing statistics into a computer. That’s not what a TA should do … A TA should be doing
stuff with the Consumer”. Other practitioners explained how they would like to see an increased focus on a
clinical role for TA/AHA in future and believed that this was also the preference of TAs. In the majority of cases,
the percentage of time allocated to particular aspects of the TA/AHA role was unclear. One practitioner
indicated that “90% of their [TA’s] day is patient contact”, but this did not appear to be the norm for TAs. The
usage of TAs by practitioners tended to focus on administrative and practical tasks.
In most cases, TA/AHAs were based in centres, clinics or hospital contexts, rather than a person’s home or out
in the community. Practitioners who worked in Consumers’ homes noted that they had rarely observed TA/AHA
operating in this context -- “…you don’t see many of them [AHAs] working in the community, that doesn’t mean
that they are not there, only in the context of CR I see more volunteers and lay people”. Most practitioners
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
154
described only minimal experience of using TA/AHAs successfully in CR work, but recognised that with
appropriate supervision and training, the role would be beneficial. However, they also noted that there might be
a need to broaden the scope of the TA/AHA role. For example, TA/AHA could potentially work with Consumers
in their homes, assisting with treatment, particularly activities of daily living, exercise programs, supporting them
to implement strategies as prescribed by practitioners - “I think there’s a lot of potential if they’re trained
well.…that they can actually carryout some of the treatment. Initially it's supervised and then once the therapist
feels that they’re competent, I don’t see any reason why they can’t actually carry out some treatment in the
home”. There was general consensus among practitioners that TA/AHAs should be able to take on more direct
clinical work with Consumers, and this was considered to be an efficient use of resources. However, this clinical
model of the TA/AHA implies a strong supervision and reporting relationship between the TA/AHAs and
practitioners, which presented some challenges for sole practitioners.
TA/AHAs were seen as particularly useful in rural areas where Consumers might only see a visiting CR
practitioner once a month. Many rural practitioners already used community volunteers and organisations in
similar roles. In these areas, a TA/AHA could provide more frequent contact with Consumers in their home
“…you could easily have an assistant.…to assist with those specific needs that the person has…like visit the
patient on a daily basis. For example … the rural health Nurse.…only visits the Consumer once a month and
there is nothing in between”. An even broader role for TA/AHAs included supporting Consumers to participate
in the community or therapeutic activities – “taking people to … a certain group … Bingo or whatever, and
initially going with them and supporting them through that process”. This type of support role for TA/AHAs has
not yet been explored, but was seen by some practitioners as having considerable merit.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
155
Training and Education Issues
Training and Education: Main Points of Interest
x No formal qualifications are available specifically for support personnel in CR or management of chronic conditions
in the community -- need to build skills for this workforce in the future.
x At present, some support personnel were required to complete a Certificate level course.
x Most practitioners agreed that formal qualifications should not be compulsory, but that those accessed through the
Vocational and Educational Training Sector had an important place.
x Recognition that creating a situation where all CR support personnel required a formal qualification would eventually
result in an inability to meet the demands of the workforce.
x Evidence suggested that established courses for support personnel perpetuated a “mismatch between the real
world and the education”, did not cover the range of competencies required by practitioners, or were seen as being
poorly administrated.
x All practitioners recognised the importance of providing a range of training and education opportunities for support
personnel working in CR to develop appropriate skills.
x A combination of on-the-job training, support and self-directed independent study modules was considered to be
most appropriate means of developing the necessary skill sets.
x Any training or education initiative offered to support personnel must be focussed on skill sets that are manageable
at their level.
x Job placements were considered an important element of training and education.
No formal qualifications are available specifically for support personnel in CR or management of chronic
conditions in the community, and many practitioners saw a need to build skills for this workforce in the future.
… there isn’t to my knowledge anything in CR that would be applicable to that level of staff [SP]. I don’t
know whether it’s worth the direction but I think CR and management of chronic disease and those
types of things in the future - it’s massive in regard to what community services are going to have to
cope with and in reality we need to use that part of our workforce as well. So to me it would be about
looking at suitable qualifications for those people.
At present, some support personnel were required to complete a Certificate III or IV (e.g., AHA, PCA), either as
a prerequisite to taking on the role, or as an expectation that study will commence during their employment –
“…if they haven’t got it [Certificate III], they will be expected, well the expectation is that they will attempt to
obtain it within a reasonable time. We promote that”. Most practitioners agreed that formal qualifications should
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
156
not be compulsory, but that those accessed through the Vocational and Educational Training Sector had an
important place.
…she’s [TA] doing external study which I think has helped. Probably more, it’s helped her across the
board, like with workplace management and prioritisations….Because it is quite hard when she’s got so
many disciplines going,[to determine] what a priority is, she’s got to think to herself what the priority is
against all of their priorities. I think her having that training as well has helped.
However, there was some evidence to suggest that established courses for support personnel perpetuated a
“mismatch between the real world and the education” or did not cover the range of competencies required by
practitioners – “there is a TA traineeship through the Australian Physiotherapy Association and I think TAFE
has got some TA training thing. We felt that didn’t cover enough stuff for what we wanted them to do”. Some
other courses relevant to CR support personnel were seen as being poorly administrated – “they’re going
through a new course for Certificate III in Allied Health Assistant, which hasn’t been particularly successful, not
really the course but more the administration of the course and that’s something that QH staff have feedback on
as well.”
Many practitioners did not feel it was appropriate for all support personnel to undertake compulsory degrees, as
“some skill sets do not require formal qualification” and it was “unrealistic to think everyone will go off and do a
CR qualification”. Indeed, there was recognition that creating a situation where all CR support personnel
required a formal qualification would eventually result in an inability to meet the demands of the workforce – “…
there are definitely skills and competencies that we could give those people without saying well somebody
without a diploma in CR can’t be involved in community rehabilitation because I just think we’re setting
ourselves up to not be able to cope with the demand”.
Without question, all practitioners recognised the importance of providing a range of training and education
opportunities for support personnel working in CR to develop appropriate skills. Developing competencies for
support personnel was considered “tricky”, however, as most of these roles were unregistered and there was a
great deal of variability in the skills required, depending on their work setting.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
157
A combination of on-the-job training, support and self-directed independent study modules was considered to
be most appropriate to develop the necessary skill sets -- “it’s probably being more lateral with the way that you
look at … support and qualifications and things like that…are there independent competencies that we can
[expect] people to self-maintain?”. One practitioner advised that any training or education initiative offered to
support personnel must be focussed on skill sets that are manageable at their level – “it needs to be suitable for
their skill level. So they need to be able to manage, that is ultimately the thing. There’s no use putting up a
course or a skill that people at that level are not going to be able to manage”. Practitioners described several
interesting examples of self-directed or in-house training and education for support personnel that were viewed
as being successful. For example, in one organisation, support personnel downloaded workbooks to complete
in their own time and competency elements were signed off by their organisation.
Most practitioners indicated that support personnel received mandatory in-house training in certain core areas
on an annual basis, such as manual handling, transferring, workplace health and safety, infection control.
However, further training and education priorities were considered to be driven by the needs of particular
services, regions or periods of time – “If there’s something they need to be trained in, it’s done”. In one
example, a CR team had developed their own extensive in-house training and education package for TAs. TAs
participated in 22 sessions, spanning such topics as basic anatomy and physiology, lifting, and transferring. In
addition, each practitioner on the team conducts several sessions with the TAs. TAs moved through the
competency levels after being tested at the end of each session. Practitioners associated with this program
indicated that they had received positive feedback from TAs about this in-house training, noting that it was very
comprehensive. However, not all practitioners felt it was appropriate that they were responsible for facilitating
education of support personnel – “I think the people that are going to do these things, they are going to be
employed by QH they should have a proper training course…we can never have the time to train them
properly”.
There was general consensus, however, that the most appropriate training and education must include on-thejob training, directed and supervised by CR practitioners, combined with a range of formal and informal
alternatives for the development of specific competencies -- “…they’ll [TA] need to have some sort of structure
set up so that they are monitored. They have the performance appraisal process, that’s all been set up and that
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
158
gets reviewed…. they have goals… and standards and competencies that they want to meet through an active
role”.
Accompanying practitioners on home visits and observing real-life settings was considered to be the most
valuable learning opportunity for support personnel, as the breadth and scope of CR work was difficult to
explain without practical application.
I think the hands on [is important]. Going out on visits with the therapists and seeing the specific cases.
But I’m just thinking back when she [TA] first started and to sit down and try and explain what we did
was really quite hard because we do so much. So to actually have her out there with us made all the
difference.
Job placements were also considered an important element of training and education for support personnel.
AHAs currently participated in initiatives such as the Allied Health Professional Enhancement Program (AHEP),
where placements were organised for them in other towns, providing them with valuable opportunities to
observe what others were doing and develop support networks. Unfortunately, appropriate placements were
extremely valuable, and difficult to locate -- “it is difficult to find a placement for an AHA in some instances. But
we managed. … we did get placements and they are well supported and they are enjoying their placement”.
Although Traineeships were seen as a useful way to train support personnel, several participants described a
recent AHA Traineeship initiative as a “spectacular disaster”. Community Health practitioners described a
“poorly managed” 12-month traineeship that was imposed on them with no prior consultation – “…everyone is
extremely frustrated. And I think this is one of our biggest problems … at the moment … no one asks us if we
wanted them. They just turned up one day”. This initiative required Community Health practitioners to supervise
unqualified and inexperienced trainee AHAs for a period of 12 months. The practitioners perceived the initiative
as a waste of time because there was no funding to continue the contract past 12 months – “I mean we’d train
them if we knew that they were going to work with us [but] we’re training them and they’re not working with us
[in future]”. According to one practitioner, “…we’re so short-staffed. I kind of spend time with her and she
doesn’t get it or she chooses to do certain things and not other things. …I think is more of a burden at the
moment … It’s just the whole traineeship. It’s been a poorly managed. There was a person who was supposed
to be managing [the program] and I’ve never even met her”. Despite the negative experience with this
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
159
Traineeship, practitioners still perceived that it was necessary to support placements for TA/AHAs, particularly if
the role became a permanent part of their team.
Supervision
Introducing a support personnel model of CR will necessitate a structure for formal supervision and
performance appraisal. However, supervisory roles were viewed as a source of increased workload for
practitioners, particularly when they were the only practitioner in a particular region. Some practitioners
described working with support personnel as a “big pressure” and were adamant that “if…there are going to be
support persons, we [practitioners] need to know how to work with them…”. One of the main concerns
expressed by practitioners was that without constant supervision, support personnel could potentially execute
tasks incorrectly or make poor decisions when supporting Consumers – “if they [SP] haven’t been trained in
anatomy, biomechanics, they’ve got no idea whether that person [Consumer] is doing it right, because they look
like they are doing it right, or they could be not hurting them, but not making it better”. There was concern that
TA/AHAs might modify a treatment regime without input from the practitioner, leaving practitioners liable in the
case of legal consequences. It was of utmost importance to practitioners that they trusted their TA/AHA to carry
out their instructions and not take matters into their own hands. Some practitioners found it time consuming to
work with TA/AHAs, due to their lack of training and experience, and their inability to make appropriate clinical
judgements based on a Consumer’s unique needs.
…[a] concern that I have in terms of using support people, is that as a professional you look at each
Consumer as an individual, and you determine what that person needs to get where ever they need to
go…what worries … is that when you have a support person they might take something that they have
seen you do with a Consumer, and apply it universally…
As a result, practitioners had to provide detailed instructions for TA/AHAs for each individual Consumer.
…they don’t get a lot of training as such … and then with each individual case you’ve got to sit down with
them and show them exactly what it is that they have got to be doing, otherwise … we’ve found that
somebody who is doing home program, they go off on a bit of a tangent and they just add things in, and
they mightn’t necessarily be what’s wrong with Mrs. Davidson is what’s wrong with Mrs. Smith, they seem
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
160
to work for her. So there’s not that connection between, that’s not clinically appropriate to do for that
person, and why.
The difficulties associated with supervision were compounded by the fact that it was necessary to create a work
environment where personnel could access sufficient support. Debriefing was considered vital to the emotional
and professional well-being of support personnel, highlighting the sense of responsibility felt by practitioners.
Delegation is Difficult
The issue of delegating tasks to support personnel arose many times, with some practitioners describing
themselves as being hesitant to relinquish some aspects of their role. Practitioners who relied heavily on
support personnel in rural and remote areas, explained that they had no choice but to “let go of some of [their]
professional…strings” in CR work, and “be willing to teach other people about your profession so that they can
continue on with those programs”. However, in some instances, practitioners were reluctant to give up their
expert role, and therefore would not easily let go of some tasks.
…that’s part of my role as well, but showing people how to make up thickened fluids and how to modify
their diets, cause I do spend time in the kitchen with the blender. So I’m an expert at making up
thickened fluids, actually I quite like doing it, so I don’t think I want to give that up. But I guess that
could be something a support person could follow up, once they’ve been taught
Some reluctance to delegate certain tasks appeared to be driven by a sense of personal responsibility for the
process of CR, implying that it was unfair to “dump” undesirable tasks on support personnel if it was genuinely
part of a practitioner’s role – “if it’s part of your role … that you do your documentation, you can’t expect
someone else to write your notes. I don’t like that idea”. In order to delegate appropriately, practitioners
required confidence in their own skills, so that they could transfer knowledge and instructions effectively to
support personnel.
I think you’ve got to be confident in your own skills to start with. Feel like you do know what you’re doing
so that you can then start to direct other people to support the rehabilitation that you’re trying to do with
people. So that if you have an [ATSIHW] … checking up on someone they know what it’s for.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
161
Confidence to Communicate
It was generally considered important to practitioners that TA/AHAs had the confidence to communicate with
them about a variety of matters pertaining to their work. For instance, practitioners noted that support personnel
required the ability to recognise when they would benefit from support and seek out that support as needed.
…they [AIN or PCA] need to be able to debrief through supervision, but also if something emotional
happens they need to, the support person themselves needs to be able to reflect and get that off their
chest so that they can get that off themselves. You’ve got to look at your AIN or Carers ability to handle
the situation….you support their emotional and professional needs and go a little further. So they’ll
know that they’re supported and can go to someone and talk to them about whatever it is, work related
that is.
Practitioners also relied on TA/AHAs to report to them about how a Consumer was progressing, and even
sought their input and observations.
… the patient would be set exercises by a Physio and the TA would go out and do it. The Physio
wouldn’t be involved at all and he’d [TA] come back and say, ‘I did those exercises, I know he’s doing
really good, is there something else you want him to do, I think he could do this’
However, some practitioners expressed mixed feelings about the extent to which they wanted their TA/AHA to
communicate views and concerns. On the one hand, it was imperative to communicate openly, even if it was a
delicate subject about the performance of a professional that might endanger the well-being of a Consumer.
…say I did something like, I put the person in a dangerous situation which you [TA] don’t agree with …
you might be the TA and I’m the physio and you could say something, which I hope you would. But
some of them [TAs] get intimated and then they go, ‘I’m not going to say anything’.
In contrast to this view, it was clear from other practitioners that communicating was a delicate balancing act for
TA/AHAs. Although practitioners valued input, they did not appreciate being questioned by TA/AHAs as this
undermined their trust that the TA/AHA would follow instructions when unsupervised -- “of my four TAs,
probably there would be three of them that I would trust to do it [work autonomously with Consumers in the
community]…. And one … [TA] has corrected therapists in consultations”.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
162
Funding and Remuneration for Support Personnel
There was some discussion by practitioners regarding the issue of remuneration for valuable support
personnel, particularly in relation to roles that had previously been supplied by volunteers. Some practitioners
believed that significant roles (e.g., community representatives or community workers, health promotion roles,
disability awareness roles) warranted funding.
I’d be highly supportive of putting some money into that [Community Roles]. But I don’t know whether they
need to be Health employees and be part of the establishment....You have to be prepared to put the budget
into that, you have to pay people to do these roles.
Despite supporting the idea of funded roles, most practitioners commented on the general lack of funding for
support personnel, particularly, but not limited to, rural and remote areas. The lack of funding for support
personnel had an enormous impact on Consumers’ ability to return to their original community following a
period in hospital, if there is no support available in their area.
…because we are a state wide service, we would try to … provide services to remote and isolated
areas.…it’s very much dependant on whether or not we can actually realistically engage Carers, provide
them with support…resource wise, we don’t have the funds to do that regional servicing…when a
Consumer wants to relocate to a regional area. It works all right,… in the city, but you try and achieve what
the goals are which is perhaps to return to your original community [in rural/remote/regional areas]. That is
hugely limited.
Main Points of Interest
x Multiple roles for support personnel are relevant in a CR framework, rather than a singular vital role.
x There is an urgent need to develop cross-sectoral interfacing and networking between support personnel and other
stakeholders that support the Consumer.
x Support personnel roles focussed predominantly on easing practitioners’ loads are legitimate, but some of the tasks
that they are taking on might not be legitimate, rather are more a reflection of lack of resources (e.g., TA/AHA
engaged in administration tasks).
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
163
x Embracing a broader perspective on the potential use of support personnel in CR, focussed more on the needs of
the Consumer, family and community, rather than the needs of practitioners is recommended.
x Consumers tended to be isolated in their communities and support to participate in the community was identified as
a gap.
x In an expanded vision of the role, support personnel have the potential to maximise outcomes of practitioner input,
but are meeting Consumers’ broader needs in line with a CR model.
x Support personnel need a range of training and education options.
The Support Personnel Perspective
Several support personnel were Interviewed as part of the current audit, namely: two Therapy Assistants
(TA/AHA), a Diversional Therapist (DT), a Physio Aide (PA), two Personal Care Assistants (PCA) (one of which
was also an Assistant in Nursing), an Endorsed Enrolled Nurse (EN) and four Aboriginal and Torres Strait
Islander Health Workers (ATSIHW). Their perspective provided an interesting comparison to that provided by
practitioners.
Being Part of a Team
It was clearly important to support personnel that they were valued members of a team – “the whole team has
been really good. You couldn’t ask for a better team…It was almost like everyone was specifically hand picked,
we’re all good at all different things. So we all come together really well”. For ATSIHW, teamwork was critical.
They preferred to think about their work as a collaboration with non-Indigenous health practitioners in that each
brought expertise without which, Consumer progress would not be possible. ATSIHW provided many examples
of poor Consumer outcomes as a result of non-collaborative practices. These health workers considered
themselves to be a resource for practitioners rather than a support – they were also a resource for their
communities to ensure adequate access to health practitioners. In one sense, they viewed practitioners as a
resource and would draw on expert Physiotherapist or Nursing advice as needed. This situation was driven by
the fact that Indigenous Consumers were often more comfortable with health workers than with non-Indigenous
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
164
practitioners. However, health workers were keen to ensure that collaborative processes were put in place to
facilitate the acceptance of CR practitioners rather than expecting health workers to do everything. Some health
workers described innovative programs where they assisted non-Indigenous practitioners to access
communities – “I always go about with the [non-Indigenous] case manager … if I've got a Consumer who is
uncomfortable … I go with them [non-Indigenous Health Worker to see the Consumer] until they feel
comfortable”.
Professional Status and Career Paths
Despite lacking professional status, support personnel believed that their role was no less important than those
of their professional colleagues. They were generally confident that their contribution to the team was valuable
– “Even though we are not professional people, I like to think with our input …can help … The idea is to help
the professionals… I'm sure I can… I’m fairly confident with what I’m doing”. However, the issue of professional
status was a sensitive topic, particularly for ATSIHW who felt strongly that their role warranted professional
recognition – “Aboriginal Health Workers need professional recognition for what they do so that they get the
recognition of being professional”, “you either overload the already overloaded [Indigenous] health worker, or
you all [them]…to have a focus on specific things, or the third option is to create a specific position”.
Taking Direction from Practitioners
Taking direction from CR practitioners was raised in almost every Interview as an important component of the
support personnel role. Most support personnel did not appear to be uncomfortable with this arrangement and
some even appreciated the lack of decision-making responsibility that accompanied the role – “we don’t go out
of our scope of practice … the RN is our boss … they’ve got the training … so we are still Enrolled Nurses and
we can’t just make decisions, which is fair enough because I’d rather have some back up”.
However, accessing professional support to approve a course of action was often inconvenient, particularly for
those who worked with visiting practitioners. When an immediate course of action was required, some support
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
165
personnel did not wait for input, confirming the fears of some practitioners – “…I used to do things [myself]. She
[Physio] would say, ‘you have to run it past me first’ and I knew I did, but she was only here twice a week … If
there is a registered Nurse here I will go ask her….her biggest issue is being sued”. Despite acknowledgement
that there could be potential legal ramifications of her work, this participant did not appear overly concerned
about her actions.
For the ATSIHW, the situation was slightly different. Although they agreed that they did work under the direction
of practitioners on some occasions, there were many examples of how practitioners worked under their
direction (e.g., when visiting a new Aboriginal community or seeking cultural advice). “The specialists are the
support personnel for the Aboriginal Health Workers -- the OT's, Physios -- they're [ATSIHW] working with the
specialists to make sure the specialists deliver health in an appropriate way”; “I take these therapists into the
home. The first time they are a bit lost but they get it eventually”. Practitioners working with Indigenous
communities in remote areas were well aware of their limitations in truly grasping the intricacies of the culture,
and recognised the need to draw on local knowledge and guidance to support their CR work – “Because none
of us are Indigenous we obviously don’t have that great an understanding of the Indigenous culture and I think,
there’s only a limited amount that we can learn. So when you’re seeing Consumers it’s very different, you need
local support to facilitate that”.
Unfortunately, some ATSIHW felt that practitioners often overlooked their expertise. Rather than being
consulted for advice and guidance, they were expected to take responsibility for every Indigenous Consumer,
resulting in an extremely large caseload. “Aboriginal Health Workers need to be respected by non-Indigenous
professionals in regard to their advice on what should happen … non-Aboriginal Health Workers … need to
know what to ask, when to ask, how to ask and they need to be able to say they don't know”; “The role of
Aboriginal Health Workers is very wide and demanding. I get referrals from everywhere. I get called whenever
anyone has any difficulty with one of our people”.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
166
Increasing Scope of Practice
Given the diversity of their role and the extent of their contact with Consumers, support personnel believed they
were an important conduit of information between the Consumer and practitioner. They often got to “know the
patients pretty closely” and as a result “we can relate to what they’re saying”. Similarly, for ATSIHW, they were
a source of knowledge about the local community and its protocols. “You've got [Indigenous] health workers
there and the community -- people you can use to come in and advise you – you don't go in thinking you know
it all and expect a good outcome. Get to know the community and respect the community or you will learn
quickly that we don’t work that way”; “If you are going into a community you have to understand the protocols of
the community -- there are [Indigenous] health workers … who can help but you have to ask”. ATSIHW were
familiar with family histories and kinship structures in the community that were not usually accessible to
practitioners. “They need to the understanding Elder system and how it works”; “You know that men's and
women's business are separate. A young woman can't ask a male Elder certain things -- he won't answer”.
Practitioners who worked with Indigenous communities and Health Workers on a regular basis were mindful of
these complex familial and social structures, clearly demonstrating the importance of tapping into local
knowledge – “…knowing that in communities there are often divisions between different families in the
community. So if you’re based in one area, a certain family might not want to come to that area because of the
other family that’s based there. You need to really be prepared [for that]…”. Support personnel were, thus, in a
unique position to develop rapport with Consumers and communities and often provided a sounding board for
both professionals and Consumers -- “Ideally we’d use those local supports as kind of a sounding board or a go
between. A liaison person who can say ‘yeah, that’s not good’… just using them [Aboriginal Health Workers] as
a go between”.
According to one Enrolled Nurse, increasing scope of practice for support personnel equated to greater job
satisfaction and retention – “I like watching and seeing different things. The Enrolled Nurses have come a long
way in the last few years, you know, a little bit more responsibility and more interesting. Sort of keeps you in the
game a lot longer”. However, in contrast to this expanded role, CR Practitioners tended to view support
personnel as just “an extra set of hands” that could assist a busy practitioner. If viewed in this broad sense,
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
167
support personnel were clearly an extra set of ears and eyes as well as an important component of the
Consumer’s network.
A Personal Care Attendant (PCA) who provided support to Consumers in their home environment following
spinal cord injury described another more detailed aspect of the role. This PCA described an expanded support
role in CR, working directly with the Consumer in a much more intimate manner than that which was previously
described by practitioners or other SP. The nature of PCA work entailed working day in and day out “right in
their [Consumer’s] personal space” and “You do see the whole person”, both literally and figuratively – “you’re
right in their face … people who need … a complete shower, …you’re washing their bits and you’re doing
everything … you get on with the job…with decorum … and respect”. This type of intimate working
arrangement required the PCA to be professional, sensible, and at all times to maintain, “respect for yourself
and for them”.
The PCA role was clearly driven and defined by the needs of the Consumer, rather than the needs of a
practitioner. A flexible, responsive, Consumer driven approach was clearly embraced by this PCA – “my role is
to do the best that I can for the person and their own specific needs. I’m someone different to everyone.…I try
to be what they need on the day”. In contrast to the work structure of other support personnel who followed the
direct instruction of practitioners, PCA respond to the direct requests of the Consumer – “I try not to overstep
the mark…I just [ask the Consumer]…’what do you want me to do?”’. The importance of balancing the provision
of support and assistance with the facilitation and encouragement of independence was key “I try and advocate
independence….I usually encourage or joke … them around to get them to have a go”.
The scope of the PCA role was described as fairly narrowly defined (e.g., showering, continence management,
assisting with activities of daily living, etc), and this participant recognised the need to expand this role further to
address deeper issues of importance to Consumers such as social isolation and attainment of life goals.
However, the participant described several barriers to fulfilling this role – including lack of skill and knowledge to
support the Consumer to identify life goals and participate more fully in his community, and lack of funding – “I
really don’t know how to get the guy more involved in the community. I can’t figure it out …Anyway, they don’t
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
168
have the funding to be able to get involved in the community”. The PCA was aware that despite being involved
in Consumer’s lives in a practical way, on a daily basis, they didn’t necessarily understand them on a deeper
level and that this was a perfect area to target through professional development initiatives – “…we could all be
better educated in learning what they [Consumers] would like out of life….”.
The need for support personnel to develop skills to avoid burnout, as well as have access to options for career
development and growth were evident in the comments of the PCA who expressed a great deal of excitement
that she was making the transition from direct Consumer contact to recruitment officer – “I’ve done enough
caring, I’ve given enough. It’s lots of giving, giving…Pretty much till you wear out…. I suppose, if you give and
give you tend to burn out. Maybe we need some education in … How not to burn out”. Certainly this has
implications in terms of the training and education, professional development and career progression for
support personnel.
Administrative Roles
Practitioners saw administrative tasks as an important part of the support personnel role. However, the topic
was only raised by one TA, who shed some light on the issue and raised a different perspective. According to
this TA, administrative tasks were unfamiliar and “scary”. Although he chose to perceive these tasks as a
learning opportunity, he acknowledged that it was a means of improving the support and level of service offered
to Consumers.
… we [TA] might get a follow up [call] after a Consumer has been here. And they may express some
feelings or some concerns or problems that they may have felt after a therapy session… we know the
patients pretty closely, we can relate to what they’re saying … So it increases that level of service [when
the TA also perform administration duties such as answering the telephone].
Thus, this TA saw administration as part of his duty to contribute to the well-being of the team “and we’re pretty
open and happy to do whatever we have to do to keep the team running”. However, administration was not
generally considered to be part of the support personnel role. This view contrasted sharply to the view of the
practitioners, many of whom considered administrative support to be a reasonable activity for support
personnel.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
169
Positive Attitude Towards Learning
The majority of support personnel expressed a positive and open attitude to learning. The manner in which they
embraced formal training and day-to-day learning opportunities was extremely enthusiastic -- “you’re pretty
much learning as you go. You’re learning on the job, your learning through in-services, you’re learning through
literature”. Support personnel displayed a proactive approach to learning, viewing each new challenge as an
opportunity for growth and development.
Most support personnel indicated that they would request training and education, or initiate opportunities, if
needed. They shared numerous examples of a proactive approach towards learning – “I’m on the education
Focus Group, if we see there is a need we identify the need, I write a memo and pass it on to the Focus Group
… and it is their responsibility to organise a training program around that area”, “I feel adamant about that….I
don’t have a problem with approaching people [on the team to ask for training]”.
Participants described themselves as enthusiastic learners – “I’m like that it’s just my nature”, and believed that
all learning opportunities were useful – “I don’t think anything you learn is a waste of time and my problem is I
don’t have enough time to learn everything I want to know”; “no matter how often you have it, there’s always
something you can pick up. There’s always something new you can learn about”, “You can always [find] value
from any sort of training”. In order to support this thirst for learning, participants commented on the importance
of the right workplace culture -- “very approachable people and no question is ever stupid”.
Some organisations arranged regular opportunities for support personnel to access training and education – “At
our monthly meetings we always have some form of education. Some sort of in-service, whether … we get
someone in from the outside like Alzheimer’s or somewhere like that”. Inclusion in training and education
opportunities with their professional colleagues was considered to be an important indicator that they were part
of the team. Conversely, exclusion from some educational opportunities was seen as inequitable and
problematic “I got invited to a lot of things, for example, they had training….so I always felt part of a team …
rather than being left out, because the professionals go to this and you don’t because you're not a professional,
so you stay here”.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
170
Some support personnel identified lack of funding as a barrier to accessing training. In many cases, their
education was self-funded, “I don’t think there is enough training and the other girls that I work with; well I’m
funding more myself. If they don’t fund it and they are not prepared to fund their own education then they are
not getting the training”. Some participants shared constructive examples of how they had independently
addressed their education and training needs. In one case, a TA had proposed a system of regular in-service
training between team members that would benefit the professional development of the entire team. A culture
of reciprocal learning and information transfer was fostered by this initiative and the collaborative relationship
between practitioners and TA/AHAs was acknowledged – “…we … thought, ‘hang on, we’ve got a good
opportunity to do some in-service’…. it’s now stemmed to the point where even the TAs are going to give inservices [to the practitioners]”.
A number of support personnel had either completed, or intended to complete, formal qualifications related to
their role. Generally, education was seen as a positive experience that resulted in a broader scope of practice.
I did the Enrolled Nurses course, it was twenty years ago now. But I did [another course] about five years
ago … our scope of practice has widened now - it was a twelve month course, through work, and we were
taught how to give insulin, do wounds and things like that, you know just … it’s very interesting … the best
thing I ever did.
However, there were some barriers to formal education identified, including changing syllabi, demanding work
schedules, lack of appropriate delivery methods (e.g., online), waning motivation, financial burden, and lack of
incentive for effort. These barriers were seen as major disincentives to completing a formal course. When
considering the commitment involved in a formal course, participants were aware of the required investment of
time and energy, and queried whether it was a worthwhile use of their time - “I could sit up to midnight and
study every night if I wanted to and if they had it online I would probably do it… it’s just having the drive to do
it….I would rather put my time into the people that need it [my help]”.
For ATSIHW, training was more formalised, but the utility of training remained an issue for them. Most ATSIHW
were required to complete a certificate qualification in order to retain employment at QH. However,
remuneration and career structures were problematic for these support personnel as noted by a manager of
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
171
ATSIHW -- “any talk about competencies implies the ability to move up levels….they [ATSIHW] are boxed in by
the current career structure”.
Networks of Support to Facilitate Learning and Sharing
Creating and tapping into supportive networks of peers and colleagues, both within, and external to the
team/organisation, was important to the professional development of support personnel. Networking with other
support personnel across the state appeared to be an emerging culture of peer support that fostered
information sharing, and the development of skills and knowledge through the exchange of experiences and
ideas. Emailing, telephone contact and networking visits had enabled TA/AHAs across the State to function “as
a big Queensland team”. This peer support network was considered to be a “valuable resource” that warranted
their “enthusiasm” and “commitment” to ensure that the channels of communication were maintained. The
benefits of being part of an association of colleagues included shared problem-solving and exchange of ideas
and support.
Support personnel Perspective: Main Points of Interest
x Support personnel wanted to be considered valued members of a team.
x ATSIHW preferred to think about their work as a collaboration with non-Indigenous health practitioners and
considered themselves to be a resource for practitioners rather than a support – they were also a resource for
their communities to ensure adequate access to health practitioners.
x Despite lacking professional status, support personnel believed that their role was no less important than those of
their professional colleagues.
x ATSIHW felt strongly that their role warranted professional recognition.
x Most participants felt comfortable taking direction from CR practitioners and recognised this as a key aspect of
their role.
x Accessing professional support to approve a course of action was sometimes inconvenient, particularly for those
who worked with visiting practitioners.
x ATSIHW shared many examples of how practitioners worked under their direction rather than vice versa.
x ATSIHW were expected to take responsibility for every Indigenous Consumer, resulting in an extremely large
caseload.
x An expanding role for support personnel was described, as they believed they were much more than just an extra
set of hands – they were an important conduit of information between the Consumer and practitioner as they
often developed close relationships.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
172
x ATSIHW, they were a source of knowledge about the local community and its protocols.
x Support personnel were in a unique position to develop rapport with Consumers and communities and often
provided a sounding board for both practitioners and Consumers.
x Increasing scope of practice equated to greater job satisfaction and retention.
x The majority of support personnel expressed a positive and open attitude toward learning, viewing each new
challenge as an opportunity for growth and development.
x Support personnel valued different forms of training and education, including formal options (e.g., TAFE
Certificates), in-house opportunities offered by their organisation, self-initiated learning and observing colleagues.
x Barriers to formal education included, changing syllabi, demanding work schedules, lack of appropriate delivery
methods (e.g., online), waning motivation, financial burden, and lack of recognition or remuneration for effort.
x Most ATSIHW were required to complete a certificate qualification in order to retain employment at QH– yet
remuneration and career structures remained problematic.
x Networking with peers was an important means of support and learning for support personnel.
Issues for Consideration in Future
The data in this study has highlighted the fact that current CR practitioners have significant workloads and
demands placed upon them and recognise the need for support personnel. They acknowledged the important
and innovative role of support personnel in the process of CR. However, few practitioners had used support
personnel and most models of practice were based on inpatient or hospital-based models where assistants
were more common. These models clearly required modification to suit the community sector. There was
considerable complexity in the nomenclature and activities of support personnel across CR services and
contexts. This complexity highlighted the lack of cross-sectoral cooperation and the lack of clarity about
boundaries between CR and ongoing disability support. These issues required attention, particularly given the
fact that practitioners promoted a support role that interfaced between the sectors and the multitude of
stakeholders.
There was a relative absence of data relating to the interfacing and networking between the Consumer, various
support personnel, CR practitioners, family/natural supports, community, and services provided by other
government bodies such as Disability Services Queensland (e.g., Community Access Workers, Local Area
Coordinators). There is clear evidence of a need to explore possible processes for enhancing cross–sectoral
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
173
interfacing with other agencies and departments that reflect the core principles of CR. Such collaboration will
also enhance the efficient utilisation of resources.
The limited dialogue that did emerge regarding cross-sectoral collaboration identified clear and profound
benefits to be gained by Consumers, as well as the health and disability sectors. One participant from the notfor-profit sector indicated that in the first instance, they lacked a “good understanding of what resources QH
puts into our Consumers once they leave the hospital system” resulting in untapped resources -- “There
potentially are sources [of support] that we could be turning to that we do not use”. Information sharing and
relationship building between the sectors, particularly during transition periods from hospital to community, was
only occurring as a result of the ad hoc effort of individual practitioners, rather than through any formally
established processes – “We [not-for-profit support organisation] need to know who all of the contact people are
[in the health system that work with Consumers], what we can expect of them. Now that’s improving but that’s
improving because of individuals who are creating relationships, not necessarily because it’s what we always
do”.
It was recognised by CR practitioners that there was no clear division between their work and that of support
personnel who worked directly with Consumers. They noted that support workers had regular and sustained
contact with Consumers, so would be a valuable addition to the CR team – “actually briefing the [Personal]
Carers in terms of where we could be at, things that we could be looking for, things they want to hear about,
because the [Personal] Carers are going to see that person everyday. …. and often that’s the only person that
Consumer sees everyday”. In contrast to this situation, support workers were engaged in activities that directly
related to rehabilitation goals with no input from CR practitioners.
[PCA] staff …are asked to do a passive exercise but perhaps only trained by another staff member. So a
bit like Chinese whisper, they don’t necessarily get it quite right, so that is a concern to us. And obviously
would be a concern to the Consumer’s rehabilitation….We’re actually trying to get back to the core
information from the Physio themselves… it’s a big gap, because that’s actually not happening now.
At a broader level, cross-sectoral collaboration could potentially reduce costs to the health system in that nonprofit organisations provide an essential support service to Consumers of the health system that if executed
well, can prevent re-admittance to hospital.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
174
There are so many not-for-profits out there giving great services with very limited resources to the
Consumers of the department of health. And if we can get it right, if we can do good skin care. If a person
with a spinal cord injury gets a pressure sore, they can have a bed in the hospital unit for up to eight to
ten months. If our staff are good enough that we can stop pressure sores developing we’re saving a huge
amount of money in health.…the savings in [hospital] beds is huge and that to me is really a huge saving.
Not-for-profit organisations have limited resources to develop appropriate training and education materials for
their staff, particularly mediums that suit rural and remote areas. Sharing knowledge and resources between
sectors, including health, disability, Universities and TAFE, was a fertile opportunity for cross-sectoral
collaboration.
I mean, we’re core to being able to deliver these services. And have peoples’ rehabilitation occur in the
home. We’re core to that. But we don’t have the resources to produce DVD’s and videos [for training and
education]. To actually have someone write a training manual is a huge expense. Whereas health
already has people who deliver training. Or the Universities, the TAFES…
A major question that was implicit in the discussion involved the point at which therapy-based rehabilitation
ceased and lifestyle supports began. Support personnel were not operating from clearly defined roles and
tended to be suspended between the needs of the Consumer, the demands of practitioners, the requirements
of the health and disability sectors, support groups and the community. Support personnel reported that their
roles were diverse, and that they often lacked the knowledge, guidance or support to develop collaborative
relationships with other workers.
Community Based Workers
Practitioners and support personnel both discussed the notion of a broader role for support personnel in future.
Locally based support personnel were considered to be particularly beneficial to CR as they could easily relate
to Consumers and quickly develop rapport that was necessary to underpin CR activities – “She is a country girl
so a lot of people are happy to tell her what’s happening and she quite easily gets rapport and respect”. Some
practitioners, for instance, described how roles that were traditionally filled by family and volunteers could easily
become paid positions. One practitioner, for instance, described a role titled Community Based Worker (CBW)
– someone from the local community who was employed to do some follow-up work with Consumers in the sixCompetencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
175
week gap between practitioner visits. Although the role was not fully defined yet, it was seen as potentially
beneficial to remote communities. The CBW was evolving into a triage role (e.g., use a simple checklist with
new Consumers prior to the practitioner visit, introducing the Consumer and family to CR and the roles of
different disciplines, general preparation for practitioner visits and setting up equipment etc).
We’re actually looking at Community Based Workers at the moment through our service… looking at how
we can employ people in our communities, that live in the community to do some of the follow up work …
that they could do for us in the six week timeframe when we’re not there. It’s more motivational, just
legality wise, we can’t have them doing a lot like prescribing or anything like that but we’re looking at
developing checklists that are just simple yes and no.…for example if we get a child with a developmental
delay, we get the referral but we’re not in town for another four weeks. They could possibly go to the
family, talk to them about what an OT is or talk about what a Physio is and then maybe do a simple
checklist of like, can the child walk. Just really simple, that doesn’t involve a lot of skill base but can just
help us, give us a bit of a head start before we get there.
A unique support role that was identified and utilised by several CR practitioners was the Community
Representative (CRep). According to practitioners, the CRep was a respected member of the local community
who had an interest in health, and participated on a Community Panel once or twice a year to have input into
CR and disability issues in the district. The CRep would act as a conduit between the community and the
practitioners. Their role was to communicate feedback about the community perspective on CR practices - what
was being done well and what needed to change. This role provides important feedback for CR Practitioners,
given the need to ensure community engagement and involvement as an important partner in the process. The
CRep would also facilitate acceptance of CR practitioners by the local community. In addition, community
members and Consumers should be aware that they can approach the CRep if they have a health problem.
One practitioner described how “we’ve started linking up with a CRep a bit more when we’re in the community
… so they might come around, walk down the main street with us. Just be seen with us. So we’re more
accepted”.
This type of position was described by several practitioners as a successful model of engaging the community
that could potentially be expanded to incorporate a more comprehensive model of CR support. Specifically, it
was suggested that the role could involve the processing of local knowledge, providing a source of knowledge
of local service networks, protocols and a broker of cultural understanding. The position would embrace dual
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
176
responsibilities, supporting CR together with disability and health awareness in the community. The main focus
of the role would be to facilitate and enhance networking and collaboration among the Consumer, CR teams,
organisations, community, and other health and disability services/sectors to promote a smooth continuum.
Although volunteers have traditionally filled most community roles, some practitioners identified scope for these
roles to be paid and associated with greater responsibilities. These roles were seen as having the capacity to
absorb some of the time consuming tasks that hindered CR, but also as providing a valuable activity that could
alleviate demand for CR in the community in future (e.g., health promotion and disability awareness, networking
and accessing local knowledge, supporting implementation of therapy regimes, supporting Consumers and
facilitating their emotional and social well-being, facilitating the transition to long-term disability lifestyle support
services). Issues for consideration regarding this type of position are:
x
Funding Implications: How would such a role be funded in a sustainable way? The need to be
locally based was evident, but there would not always be strong demand in every community.
Should funding fall to the health sector, disability sector, local government or to the private sector?
The auspicing base will have implications for the frameworks that are adopted by the role.
x
Training Frameworks: A complex set of skills is required, but the local nature of the role will
exclude the likelihood that specific training requirements can be imposed. There must also be
capacity to build on a range of existing training backgrounds and skills to maximise choice in
recruitment.
x
Disciplines: A high level skills is required to interface and manage complex issues in communities –
should this role be associated with an undergraduate degree in case management, community
development or health promotion? This requirement would denote significant promotion of training
opportunities in local communities, often with no guarantee of work in smaller regional, rural and
remote areas.
The CRep position clearly has the potential to expedite and establish ‘cross- sectoral’ collaboration. The role
would encapsulate many core CR principles and facilitate CR implementation in local communities. Despite this
expanded role, the role of Therapy Assistant was still viewed as being crucial to the CR process. This role was
viewed as a clinically oriented role that responded primarily to the therapist, but interfaced closely with the
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
177
Consumer. Although a broader scope for support personnel was suggested by all parties, there was evidence
from Aboriginal and Torres Strait Islander Health Workers that a broad scope of practice led to significant
workload concerns. Thus, it may be necessary to consider the existence of two distinct but related roles, a
Therapy Assistant (e.g., CR Assistant, Physio Aide, OT Aide, Speech Pathology Aide, Enrolled Nurse) and a
Community Based Worker devoted to community development, non-clinical Consumer support and
collaboration. Future research needs to investigate current models of support personnel that have been tested
in the literature.
Competencies for Community Rehabilitation in Queensland - February, 2006 - Griffith University
178
International Comparisons
179
It was noted that considerable investigation has already been conducted into the training needs and
skills/competencies of providers of community rehabilitation in areas of Canada and the United States of
America (USA) similar to Queensland (e.g., southeast rural areas based in Tennessee [Region IV], the
southwest desert region based in California [Region IX] and the Midwest farmlands region based in
Illinois/Wisconsin [Region V]). Throughout the USA, a Community Rehabilitation Providers Rehabilitation
Continuing Education Program (CRP-RCEP) network1 has been established to meet the demands of
community rehabilitation services for adequately trained professional staff. The work of the CRP-RCEP network
has been organized and directed, in part, by the Association of Community Rehabilitation Educators (ACRE).
This section of the report provides an overview of the history of CR development in both countries, and a
discussion of the competencies identified by the interview participants.
Background and Brief History of CR in the USA and Canada
Beyond the specific legislative influence on CR, Neufeldt (2003) in his work, “Disability in Canada: An historical
perspective,” provides an apt and concise summary of the background and history of CR not only in Canada,
but also, to some extent, in the USA:
By far the most intensive period of development was the four decades following WWII. Building on
changes in social values and increased emphasis on science and knowledge, major innovations were
introduced by a succession of disability groups: war veterans, polio/post-polio, mental health, intellectual
impairment, self-advocacy. The overt emphasis was on challenging traditional ‘charity’ and ‘medical’
model approaches to disability, and in developing resources and supports to enable more dignified and
meaningful community living (p. 74).
The Canadian view of CR has taken as its base a commitment to human rights and social justice whereas the
American underpinnings have remained focused on medical intervention and vocational rehabilitation.
However, key informants from both countries acknowledge the important role of advocates for persons with
developmental disabilities in promoting the shift towards CR. Specifically, Neufeldt (from Canada) along with
co-author Egers, (2003), noted that the “emergence of psycho-social-ecological understandings of disability is
1
The first CRP-RRCEPS were funded in 1995; the funding level is USA $500,000 over 5 years.
Competencies for Community Rehabilitation in Queensland – February, 2006 – Griffith University
179
best illustrated by the development of education of personnel in the developmental disability field, in that this is
where much of the innovation took place.2 Up to the late 1960s, few service personnel had any reasonable
level of education in developmental disabilities….” (p. 311). The authors further discuss how the training of
personnel to work in “community living” homes or facilities and the “newly emerging community-based services”
emerged (p. 311).
A USA key informant revealed the same connection with developmental disability in the history of CR programs
in the USA:
Many [programs] started out as efforts of family members who wanted to protect their children—family
members who tried to get activities for their children or young adults – individuals with mental
retardation, Downs Syndrome, etc. - families came together wanting to avoid institutionalization for their
children. Their networking resulted in local ARCs3 [formerly, Association for Retarded Citizens of the
United States; since 1992, simply “The ARC”]. There might have been connection to medical centers.
Larger federations developed such as Jewish Vocational Services, Easter Seals, and Goodwill
Industries. Over the 20th Century, there was the development of specific CR programs that formed to
meet the needs of specialized populations and topical concerns, for instance, physical needs, social
needs, e.g., day activities.
The 1970’s in the USA saw the beginning of conflict in these early CR organizations about whether or not they
should advocate for gainful employment in the community or remain focused on “sheltered” work and nonvocational concerns. These concerns occurred at the same time as the de-institutionalization movement in
mental health and the independent living movement instigated in part by war veterans – this time from Vietnam.
This movement altered the nature of CR in the USA to a vocational service.
As one example of movement toward community rehabilitation [and the drop of any named link to developmental disabilities] in the
developmental disability field, consider the name changes of one organization: Canadian Association for Retarded Children (CARC)
changed in 1969 to Canadian Association for the Mentally Retarded, and again in 1984 to Canadian Association for Community
Living.
2
As in Canada, the national association that advocates for persons with developmental disabilities has gone through a series of name
changes that progressively leave out reference to a disability; these changes are delineated at
http://www.thearc.org/history/names.htm.
3
Competencies for Community Rehabilitation in Queensland – February, 2006 – Griffith University
180
Federal Legislation drives the nature of CR
Both Canadian and USA interviewees noted that the nature of CR was based in the Federal legislation of their
countries. For Canadians, the Canadian Charter of Rights and Freedoms [Section 15] (1982) reflects a “rights
perspective” or as Neufeldt (2003) described, a “rights culture” (p. 75). This culture strongly directs how CR is
perceived in Canada. The Canadian Charter of Rights and Freedoms, as part of the Canadian Constitution,
represents their basic belief in the rights of citizenship. The Canadian key informant noted, “We have also
bought into the UN Declaration of Human Rights (www.un.org/overview/rights.html)….People are equal before
and under the law. Discrimination is prohibited based on physical or mental disability….We are talking about
equality".
The Canadian legislative perspective of a “rights culture” contrasts sharply with the USA perspective. The
Federal legislation that directs CR in the USA is the Rehabilitation Act of 1973 amended 1998. This legislation
creates an “eligibility” program and not an “entitlement” program. In brief, there is no “right” to rehabilitation
services, but rather the individual must be deemed eligible for services. The USA program is focused on
returning individuals to productive roles in society, particularly vocational.
These differing perspectives have implications for the nature of CR and the training required, highlighting the
importance of a sound legislative base to set the scene. As a Canadian informant observed, “the way we
contextualize CR is more around societal participation structures - a social justice perspective. Canada comes
from an equity, level playing field, more socialist perspective rather than capitalistic. This is really foundational
to disability policy in Canada.” Thus, CR training in Canada is underpinned by the need for practitioners to
understand and work towards physical and social inclusion. Again, the Canadian informant remarked, “Work is
one very narrow perspective within the Canadian overall inclusion framework — our perspective is not ‘back-towork’ or production”. The informant suggested that the Canadians use the term “disability management” rather
than “community rehabilitation” to represent the type of CR that dominates the USA system. Disability
Management is a model of rehabilitation that focuses on how the entire community can contribute to the goal of
returning and maintaining individuals with disabilities in the workplace.
Competencies for Community Rehabilitation in Queensland – February, 2006 – Griffith University
181
This observation was supported by the USA federal legislation as well as in the interviews conducted with
ACRE and the CRP-RCEP representatives. Specifically, in discussing CR, USA interviewees usually referred to
the 1992 Amendments to the 1973 Rehabilitation Act when the term “community rehabilitation” was first used in
legislation.4 In the following quote from the current 1998 Amendments to the USA 1973 Rehabilitation Act, the
direct link between the legislation and the nature of CR becomes apparent. The vocational focus of the
legislation is clear. Indeed, under the CRP-RCEP model, programs are required to have a vocational
component in order to be considered a CR program.
Extract from 1998 Amendments to the 1973 Rehabilitation Act
The term "community rehabilitation program" means a program that provides directly or facilitates the provision
of vocational rehabilitation services to individuals with disabilities, and that provides, singly or in combination,
services for an individual with a disability to enable the individual to maximize opportunities for employment,
including career advancement:
(A). medical, psychiatric, psychological, social, and vocational services provided under one management;
(B). testing, fitting, or training in the use of prosthetic and orthotic devices;
(C). recreational therapy;
(D). physical and occupational therapy;
(E). speech, language, and hearing therapy;
(F). psychiatric, psychological, and social services, including positive behaviour management;
(G).assessment for determining eligibility and vocational rehabilitation needs;
(H). rehabilitation technology;
(I). job development, placement, and retention services;
(J). evaluation or control of specific disabilities;
(K). orientation and mobility services for individuals who are blind;
(L). extended employment;
(M).psychosocial rehabilitation services;
(N). supported employment services and extended services;
(O).services to family members when necessary to the vocational rehabilitation of the individual;
(P). personal assistance services; or
(Q).services similar to the services described in one of subparagraphs (A) through (P).
See also document entitled, “The State VR/CRP Partnership” a CRP Brief report available at
http://www.crp.unt.edu/Design/publications/crp_brief/acrobat/march2002.pdf
4
Competencies for Community Rehabilitation in Queensland – February, 2006 – Griffith University
182
Allied Health Personnel
USA informants were divided in regard to the role of allied health personnel in CR, which had implications for
training. The representative quotes below clearly show this division, in that some allied health roles are
considered more relevant than others to CR. However, the vocational focus of the USA programs has meant
little involvement of Allied Health professionals in the past.
Our historical definition includes that vocational component. Now we are looking more at community
participation—adult care, adults with disabilities becoming seniors—so we have participation in these
adult communities. OTs are getting more involved now and iIt is an interesting shift to see this wider
definition of CR.
From the CRP-RCEP side, we only work with CR programs that have [vocational] contracts through RSA.
The larger CR organizations [e.g., Goodwill Industries] might have OT, PT, nursing, or have allied health
personnel as consultants, but they don’t run CR programs.
At our [CRP-RCEP] training, we are open to any training professionals related to disability/transition, not
just those who have a contract with RSA.
However, recent CR training announcements in the USA clearly demonstrates that allied health personnel are
not considered as being central to CR. As shown in the announcement below, the vocational focus of many
programs dominates who is targeted for training:
Who should attend?: Staff who are responsible for facilitating employment for people with disabilities
including job developers, middle managers, special education teachers, employment consultants, and
vocational rehabilitation staff.
In contrast, the Canadian position was clear that CR belonged outside of the medical framework. Although
Allied Health disciplines had been involved in CR in the past, they were generally viewed as part of the team
rather than the primary providers. Collaboration was the basis of CR: “In CR, OTs, PTs, and speech therapists
would be considered part of a multi-disciplinary practice - We’ve really tried to keep CR out of the medical
arena”. Thus, this model, as in the USA model involves the delivery of CR by trained CR professionals, who
draw on Allied Health practitioners for specialised input related to their particular disciplines.
Competencies for Community Rehabilitation in Queensland – February, 2006 – Griffith University
183
Training Issues in CR
The Rehabilitation Act of 1973, as amended, also provides for the training of personnel, by authorising the
federal government to “provide short-term training and technical instruction, including training for the personnel
of community rehabilitation programs, centres for independent living, and other providers of services (including
job coaches)” [Sec. 12. (a)(2)]. Additionally, the Act calls for “establishing standards and certification for
community rehabilitation programs” [Sec. 14. (f)(2)].
One key informant commented that the conceptual link between vocational rehabilitation and community
rehabilitation has dissipated in the USA, but they are trapped in “a love/hate relationship”. This is due to the fact
that CR funding initially “came from VR [Vocational Rehabilitation] funds, but as these funds have dried up, the
community rehabilitation folks are still held hostage to the rules and regulations in VR legislation”. One key
informant suggested that, under this model, CR programs might be seen the as the “community partners” of
VR. The informant explained that historically, “the most severely disabled that could not really be served by the
State VR model were served by workshops and community facilities. Then with legislative mandates that VR
should include the most severely disabled people, VR referred [clients] out to [CR services]. CR programs can
provide specialized services that are customized to those with more special needs. In Texas, 90% of clients are
referred out … a VR counsellor typically might have 170 clients on the caseload, she [functionally] works as a
case manager or broker of CR services”.
Thus while there is a clear “vocational component” to CR when talking with trainers involved with the CRPRCEP network, a broader picture dominates the view of community agencies and higher education providers.
As one key informant concluded, “When you get into community rehabilitation you get into multiple systems”.
It is clear that the definition of CR in each country has profoundly influenced the nature of the training that is
available in USA and contrasts sharply with the type of course work and training presented to CR students in
Canada. In the USA, typical training courses include subjects such as job development, whereas Canadian
courses include, for example, a course on international social policy. The Canadian perspective uses
Competencies for Community Rehabilitation in Queensland – February, 2006 – Griffith University
184
“community” to refer to the notion of “developing community strength and tolerance” and “rehabilitation” to refer
to an “ongoing commitment to support people”.
One key informant from the USA commented, “I think the Canadians start [training] with a different orientation—
they start with the person in the community as the centre of services—so it is truly CR. In the USA, we are tied
to RSA dollars [Rehabilitation Services Administration - the federal agency authorized to implement
rehabilitation legislation]. RSA feels responsible to make sure that the folks who provide services are
adequately trained. So we aren’t creating or training new [CR-specific human] resources we are working with
existing [RSA-human] resources.
The models used by both the USA and Canada have implications for the workforce structure. The systems
both consist of two levels of worker in CR, a Masters trained specialist in rehabilitation counseling and a noneducated CR worker. The USA and Canada share a similar perspective regarding the level of education
necessary to reach a “professional” level in rehabilitation. In both countries, it was considered necessary to
obtain a Master’s degree to be a specialist in rehabilitation (i.e., rehabilitation counsellor or community
rehabilitation practitioner). Although training in CR in both countries emphasises course work through higher
education, the USA employs para-professionals who have generic skills. One participant commented: “CR in
the USA is more about knowing resources in the community. At the Bachelor’s [degree] level, we train folks for
entry level in the community. They could be working with juvenile offenders, mental health, all kinds of disability
support programs.” In Canada, however, Bachelor degree students are more likely to have specialised in CR.
However, for those working at the coalface in CR, university level education is not required. As the Canadian
informant commented, “The practice level here in CR is the two year diploma; that doesn’t make me overly
happy, but it happens.”
The employment of unqualified practitioners in CR stands to reason given the Canadian “career ladder”
practice as described in a publication by the Canadian informants, Neufeldt and Egers (2003) below:
Rather than advocating that most personnel be trained as professionals, this model recommended that
70% receive one- and two-year college-level [US “junior/community college] educational diplomas, with
the remaining 30% divided between various levels of specialization (i.e., from bachelor’s to doctoral
Competencies for Community Rehabilitation in Queensland – February, 2006 – Griffith University
185
degree levels). It also proposed a “career ladder” whereby graduates with college [US “junior/community
college] diplomas could proceed to more advanced education (p. 312).
The USA informants confirmed that their CR programs were generally staffed by personnel who had little or no
higher education experience, or at best, a Bachelor’s degrees (other than in the management area where
higher degrees were more likely to be found). For example, one informant commented, “We get a lot of people
here who are working on their Master’s and they might do CR while in school [university], but unless they move
up to management, they might not be able to stay there because of the salaries [being too low]”.
In terms of training content, a common theme in the USA was the fact that “there is no standard”. Not only was
there general agreement that no standard existed for the training of CR employees, but there was also
acknowledgement that, “each state and region is different”. There was, however, strong support for the recent
efforts of the professional association group, ACRE, to develop a certification process and some
standardization.
Examination of the curricula across the 10 USA CRP-RCEP federal regions confirmed that topics varied
considerably. As one key informant explained, “We have an advisory committee that has helped us decide what
to train in; we are re-thinking that now and want to see how we want to fit in with ACRE’s emerging role. We
began with an assessment in the community with what they felt they needed.”
A key informant from the USA explained, “Each state has a [RSA] rehabilitation agency that contracts with a
given facility for CR services. The work of that facility or CR agency drives the training priorities [if job coaching
and support is their priority, training focuses on how to do a job analysis, how to interact with an employer etc.].
CR [agency] may not have the budget to hire a trained professional so has to train themselves; there is no
standard across the country as to the qualifications of staff in a CR facility.
In contrast, Canada has experienced more consistency in CR training as noted by Neufeld and Egers (2003).
“In terms of curriculum content, the [CR] model broke with the ‘medical model’ by adopting a values-based,
person-centred, community-oriented rehabilitation and intervention approach, from a psycho-social-ecological
perspective” (p. 312). This curriculum content model was in place and evident in higher education throughout
Competencies for Community Rehabilitation in Queensland – February, 2006 – Griffith University
186
Canada. The key informant for these interviews was quite clear regarding the stress that Canadian institutions
place on the psycho-social-ecological perspective, commenting:
We teach the students how they might influence policy. We try to make them as comfortable with
systems as we can. They know the points of change and where they need to intervene. They are not
intimidated by positions. Understanding systems change and how they might influence policy is as
important as actual practices skills with clients. Most of our training programs take a holistic approach, a
birth to death approach, and a pan-disability approach. We have made a conscious effort to be crossdisability.
Issues for the Workforce
Participants in [ACRE] training programs will accumulate a specified number of training hours on targeted
topics and earn "Certificates of Achievement" at beginning, intermediate, and advanced knowledge and skill
levels. Though not all training is necessarily linked to academic or degree programs, these certificates will
reflect successful completion of the required training and in some cases, may be credited against academic
programs. Ideally, continuing education training feeds into a “career ramp” such as described by one USA key
informant.
The way we’ve designed this, we hope we are helping folks develop a career ramp. We are getting folks
in community rehabilitation who took the job, but now they can get involved in a certificate program that is
academically-based [similar to but not ACRE]; they can go to a community college and see that they are
half-way to an associate’s degree. They can complete the certificate in a year. They haven’t seen their
work as a career path; they didn’t see themselves as college material, but now they can. Some
organizations pay the community college fees up front and then use payroll deduction to be reimbursed;
bunch of ways this is done. Employee may get a raise, a bonus if they complete the academic-based
certificate. Not sure how many of the CRPs-RCEPS have partnered to have academic credit with a
certificate; very different in each state.
However, when asked about “strengths and weaknesses of this CR system, key informants tended to respond
in terms of “weaknesses” and were particularly critical of workforce issues. Specifically, informants from both
countries cited low salaries for frontline staff, and in the USA, the lack of a career progression.
Representative quotes are shown below:
Competencies for Community Rehabilitation in Queensland – February, 2006 – Griffith University
187
The typical CR direct services staff would start at $18,000. Most likely $7 –$10 an hour - the workforce
has a high school education, typically.
What’s in it for the individuals – the line staff? They don’t make much money. There needs to be career
progression. But the people who do come to the training look forward to it—where else could they get the
training for a minimal amount—we charge just for coffee. There are no “graduates” per se; they are
looking for continuing education/training. Many don’t even have undergraduate degrees—they are
working in group homes, etc. We need to be able to offer a career progression – a career ladder or ramp.
We are starting a conversation now about how to go out and train, but also lead them systematically to a
greater level of professional development. Could we start a movement where their salaries can be tied to
career development?
In relation to the Masters level rehabilitation counselors positions, it was noted that positions are scarce due to
funding shortages.
Funding is not there for professional positions; we are dependent on public money, public government
money. A Master’s level rehabilitation counselor gets USA $32,000 at best, some at $27,000.
As one key informant noted, the “career ladder” concept had shortcomings as a result of funding shortages. He
noted that although it was the responsibility of professional educators to influence the marketplace by
improving the level of professional qualifications, this strategy may only create more tension in the system:
One weakness has to do with the lack of resources. Should we raise the professional standards so that
the state pays more for the services or do we expect folks to raise their own level of qualifications given
their tremendous responsibilities?
Low salaries and lack of opportunities for career progression are often linked to high employee turnover, a
second major weakness of the CR system as noted by key informants. High turnover made the provision of a
systematic training program extremely difficult due to the lack of consistency. Representative responses
include:
There is high turnover with staff in community rehabilitation. In trying to give them [CR workers] training
that would give them opportunities for increasing professional skills/professional identity—in CR
programs it is really interesting. The line workers are not typically able to be released for training. The
staff will be staggered – only one is let go to training—so one goes for one block and one to the other.
Competencies for Community Rehabilitation in Queensland – February, 2006 – Griffith University
188
We offer 3-5 day certification training. ‘Just-in-time’ technical assistance training. There is high turnover
with employees changing every 6 – 9 months. So, we use a train-the-trainer approach – we identify one
of the “high end” professionals who has stability [and train that person to deliver ongoing training].
For students who are receiving training in a formal higher education setting, the question of professional
identity remains an issue particularly for those who train only to a Bachelor’s level. As one key informant
described:
One of the problems for our graduates—it is hard for them to talk specifically about what they do. I don’t
know that our graduates are able to match core skill to identified role or responsibility. It is hard for our
graduates to present themselves to employers; hard for our employers to see exactly what our students
do. Students work in schools, insurance companies, family supports ministry/provincial government,
community-based homes, workman’s compensation. It is good for them to have broad work opportunity,
but it disallows professional identity.
Thus, although a strength of the system may be found in opportunities that allow some practitioners to arrive at
the top of the “career ladder,” it is unclear how this concept can be applied equitably when funding and
marketplace constraints are considered.
Competencies for Community Rehabilitation in Queensland – February, 2006 – Griffith University
189