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1 The CR Workforce 83 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. U The section describes the analysis of the understanding of CR that underlies current practice. This analysis is nderived from the Interview data with practitioners, who responded to several questions about the definition of dcr 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 aimportant it was to their CR practice. This data provides important comment on practitioners current level of nunderstanding 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 npractitioners from implementing the competencies associated with CR. Barriers were identified by practitioners gin 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 oanalysis also contains some suggestions and solutions that were contained in the data. f Competencies for Community Rehabilitation in Queensland - February, Griffith University 83

2 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, Griffith University 84

3 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, Griffith University 85

4 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, Griffith University 86

5 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, Griffith University 87

6 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: Practitioners are experts, have knowledge and skills and aim to promote Consumer s functional status Consumers are often passive recipients of a service who comply with treatment and advice De-skills Consumers and family by creating dependency, feelings of inadequacy and reduced efficacy Unique knowledge and skills of Consumers and family is ignored The Transplant Model (Mittler & McConachie, 1986) has the following dimensions: Trains and educates Consumers and family in skills/knowledge necessary to promote functional status Consumers and family are regarded as resources for expanding the coverage of the service Family members become co-educators or co-therapists, but the professional remains the instructor Sustainable transfer of skills with a two-way dialogue Practitioners are still in control The Partnership/Negotiating Model (Cunningham & Davis, 1985) has the following dimensions: Recognises the expertise and ultimate knowledge of Consumers and family Recognises diverse needs of different families Active participation of Consumers and family in decision making Professional supports the Consumers and family in making decisions Assumes Consumers, family and professional will reach agreement through negotiation Competencies for Community Rehabilitation in Queensland - February, Griffith University 88

7 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: All individuals are able to participate in goal-setting and decision-making to the degree they choose Individuals have access to the full choice of practitioners, services, locations, and methods of receiving rehabilitation Where appropriate, family members or natural supports can provide services and be supported to do this if necessary Individuals and their families are supported to engage in long-term planning for their well-being Individuals and their families are expected to be cost effective, but will not be penalised or limited on economic grounds Systemically, there is a means to manage fluctuations in need and emergencies Self-determination is available to the extent possible and desired in all programs and Informed choice is a central theme The roles and responsibilities of all parties are explained, acknowledged and formalized 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 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, Griffith University 89

8 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, Griffith University 90

9 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 I Have this practice competency Mean (SD) Rank Mean (SD) Rank 1 Frameworks of Understanding 2.05 (.78) (.88) 10 2 Networks 1.18 (.38) (.60) 2 3 Cultural Awareness 1.56 (.64) (.67) 6 4 Holistic Focus 1.13 (.41) (.49) 1 5 Consumer Engagement 1.05 (.22) (.60) 3 6 Service Continuity 1.55 (.83) (.71) 8 7 Reflective Practice 1.10 (.38) (.59) 4 8 Community Engagement 1.54 (.64) (.79) 7 9 Boundaries and Personal Safety 1.25 (.43) (.67) 5 10 Systems Advocacy 1.51 (.65) (.82) 9 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. Competencies for Community Rehabilitation in Queensland - February, Griffith University 91

10 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: Systemic Issues Associated With the Lack of Profile for CR Insufficient Organisational and Community Resources Lack of Technological Skills and Resources Lack of Structured Protocols and Documentation for CR Lack of Evidence Base for CR Workplace and Job Structures that Prevent Good Practice Lack of Flexibility and Confusion about Eligibility Criteria Lack of Recognition of a Specialised Role Vulnerability as a result of CR practice The Assumption of Knowledge New Graduates Complacency and Maintaining the Status Quo The Perception that the Consumer is the Problem Lack of Person-Job Congruence Lack of Interpersonal Skills, Self-reflection and Consumer-focus Being a Team Player Adaptation to a CR Role Clinical-Focused Practice Contextual Barriers Lack of Pre-service Education and Preparation for CR Lack of Community Awareness Culture Shock Lack of organizational and community resources Emotional and psychological issues Maintaining Clinical Competence Competencies for Community Rehabilitation in Queensland - February, Griffith University 92

11 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, Griffith University 93

12 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, Griffith University 94

13 ...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: Inability to provide a holistic service Lack of opportunity for formal team planning and 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, Griffith University 95

14 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, Griffith University 96

15 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, Griffith University 97

16 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, Griffith University 98

17 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, Griffith University 99

18 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, Griffith University 100

19 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 away, and if they do need some help, there are resources to use. Competencies for Community Rehabilitation in Queensland - February, Griffith University 101

20 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, Griffith University 102

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