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Development and Validation of the WHO Rehabilitation Competency Framework: A Mixed Methods Study

Open AccessPublished:November 24, 2020DOI:https://doi.org/10.1016/j.apmr.2020.10.129

      Abstract

      Objectives

      To identify the competencies, behaviors, activities, and tasks required by the rehabilitation workforce, and their core values and beliefs, and to validate these among rehabilitation professionals and service users.

      Design

      Mixed methods study, involving a content analysis of rehabilitation-related competency frameworks, a modified Delphi study, and a consultation-based questionnaire of service users.

      Setting

      Desk-based research.

      Participants

      Participants who completed the first (N=77; 47%) and second (N=68; 67%) iterations of the modified Delphi study. Thirty-seven individuals participated in the service user consultation. Collectively, the participants of the mixed methods study represented a significant range of rehabilitation professions from a broad range of countries, as well as both high- and low-income settings.

      Interventions

      Not applicable.

      Main Outcome Measures

      Not applicable.

      Results

      The mixed methods study resulted in the inclusion of 4 core values, 4 core beliefs, 17 competencies, 56 behaviors, 20 activities, and 62 tasks in the Rehabilitation Competency Framework. The content analysis of rehabilitation-related competency frameworks produced an alpha list of competencies, behaviors, activities and tasks (“statements”), which were categorized into 5 domains. The final iteration of the modified Delphi study revealed an average of 95% agreement with the statements, whereas the service user consultation indicated an average of 87% agreement with the statements included in the questionnaire.

      Conclusions

      Despite the diverse composition of the rehabilitation workforce, this mixed methods study demonstrated that a strong consensus on competencies and behaviors that are shared across professions, specializations, and settings, and for activities and tasks that collectively capture the scope of rehabilitation practice. The development of the Rehabilitation Competency Framework is a pivotal step toward the twin goals of building workforce capability to improve quality of care and strengthening a common rehabilitation workforce identity that will bolster its visibility and influence at a systems-level.

      Keywords

      List of abbreviations:

      RCF (Rehabilitation Competency Framework), TWG (technical working group), WHO (World Health Organization)
      Competency frameworks, which comprise organized statements that communicate the expected or aspired performance of a particular workforce, can be valuable resources in addressing workforce challenges in many settings. These challenges generally relate to a shortfall of workers, deficiencies in quality of care, and a mismatch between workforce capabilities and population needs.
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      • et al.
      Education of health professionals for the 21st century: a global independent commission.
      World Health Organization
      Global strategy on human resources for health: workforce 2030.
      • Jesus T.S.
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      Human resources for health (and rehabilitation): six rehab-workforce challenges for the century.
      Competency frameworks can help address these challenges at the individual, institutional, service, and system levels.
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      Developing a palliative care competence framework for health and social care professionals: the experience in the Republic of Ireland.
      ,
      • Belkadi F.
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      Competency characterisation by means of work situation modelling.
      Regulatory or accreditation bodies use competency frameworks to communicate the standards expected of a profession. When applied to pre- and postservice education and enforced through audits and other mechanisms, they form an integral component of quality assurance. Education institutions use competency frameworks for articulating the outcomes of their courses. They can be used to shape the learning outcomes of courses and to ensure that the knowledge and skills taught by the institution are aligned with population needs. Services use competency frameworks in workforce planning and human resource management. In the context of planning, they enable services to successfully align their staff competencies and activities with population needs and service objectives and help to identify gaps in knowledge and skills and performance deficiencies. In the context of human resource management, competency frameworks define performance excellence and provide a benchmark against which workers are assessed. They are also integral to establishing individual and service-wide development priorities. Ministries of health can apply competency frameworks in workforce evaluation and planning, such as in conduct competency gap analyses.
      Considering their broad utility, competency frameworks have a clear role in the field of rehabilitation, where workforce challenges are acutely felt, especially in low- and middle-income settings.
      World Health Organization
      Rehabilitation 2030: a call for action. The need to scale up rehabilitation 2017.
      ,
      • Jesus T.S.
      • Hoenig H.
      Crossing the global quality chasm in health care: where does rehabilitation stand?.
      Lack of access to a skilled rehabilitation workforce has substantial health, social, and economic implications. In addition, countries are facing increased pressure to take action in light of ageing populations, the growing prevalence of noncommunicable diseases and injuries, health emergencies, and other health trends.
      • Jesus T.S.
      • Landry M.D.
      • Dussault G.
      • Fronteira I.
      Human resources for health (and rehabilitation): six rehab-workforce challenges for the century.
      ,
      World Health Organization
      Rehabilitation 2030: a call for action. The need to scale up rehabilitation 2017.
      Although a considerable number of rehabilitation-related competency frameworks exist, they have typically been developed in the context of a specific profession, specialization, or setting; have largely been developed in high-income countries; and have had widely varied language and interpretation of key concepts. This poses a barrier to their use, particularly in the context of broader workforce evaluation and planning that crosscuts professions, specializations, and settings, and promotes fragmentation in the field. There is an evident need for a competency framework that harmonizes rehabilitation competencies and captures the breadth of rehabilitation activities, provides a common language, and is relevant to both low- and high-resource settings. Such a framework will support rehabilitation workforce evaluation and planning and facilitate the development of context-specific competency frameworks that are aligned with others in the rehabilitation field. Furthermore, it will promote a common rehabilitation identity, which is integral to increasing its visibility and influence.
      Moving forward with the development of a Rehabilitation Competency Framework (RCF) that can serve the above aims will require that several questions be addressed. First, what are the core values, beliefs, competencies, behaviors, activities, tasks, knowledge, and skills needed by the rehabilitation workforce? These need to be representative of the scopes of practice of the various rehabilitation professions and specializations to not only provide rehabilitation interventions, but also deliver rehabilitation services in a range of settings. The distinction between competencies, behaviors, activities, and tasks (which, along with core values, beliefs, knowledge, and skills, are hereafter collectively referred to as statements) is summarized in table 1 and is based on the conceptualization of competency framework terminology proposed by Mills et al.
      • Mills J.
      • Middleton J.W.
      • Schafer A.
      • Fitzpatrick S.
      • Short S.
      • Cieza A.
      Proposing a re-conceptualization of competency framework terminology for health: a scoping review.
      Table 1The distinction between competencies and activities applied in the RCF
      CompetenciesActivities
      Associated with an individualAssociated with work
      Continuous (transcend all activities and tasks)Discrete (begin and end)
      Expressed as behaviorsEncompass tasks
      Relevant to all rehabilitation workersRelevant to some rehabilitation workers and not others, depending on their occupational role
      Example:

      Competency: communicates effectively with the individual, his or her family, and the health care team

      Behavior: speaks clearly and concisely
      Example:

      Activity: conduct a rehabilitation assessment

      Task: analyze barriers and facilitators in the individual’s environment
      Next, are the statements deemed relevant and acceptable to different rehabilitation professionals of varying specializations working across settings? For the RCF to have impact, there must be broad consensus about its content by those to which it applies. This is critical to not only achieving the buy-in required for its uptake and utilization, but also to ensure its function as a unifying framework.
      Finally, are the statements deemed relevant and acceptable to different rehabilitation service users? It is the preferences of these stakeholders that shape the behaviors required of the rehabilitation workforce. Building consensus on relevant statements of the RCF among service users helps ensure that it is promoting a rehabilitation professional that can deliver the type of care individuals wish to receive.
      To the authors’ knowledge, there is no existing literature on the identification or agreement on statements that encompass all rehabilitation professions, specializations, and settings. In addressing these questions, the authors used 3 methodologies, involving a content analysis of existing rehabilitation competency frameworks to address the first question, a modified Delphi study to address the second question, and a questionnaire-based consultation to address the final question.

      Methods

      The development of the RCF was guided by the expertise of an international, multidisciplinary technical working group (TWG) composed of 20 members. Members of the group were selected via nomination from different rehabilitation professional associations based on the relevance on their experience and to achieve an optimal balance between disciplines and representation of World Health Organization (WHO) regions. The use of a TWG was necessary to ensure that the perspectives of each profession and of different geographic areas and cultures were considered in decision making. It also provided a forum for discussion and problem solving, which the methods used to address the 3 research questions did not allow. The demographic characteristics of the TWG can be found in table 2. Ethical approval for this study was provided by the Northern Sydney Local Health District Human Research Ethics Committee within the New South Wales Department of Health in Australia.
      Table 2Demographic characteristics of the RCF TWG
      VariableFrequency
      Profession, n (%)
       Audiology2 (10)
       Occupational therapy4 (20)
       Physical and rehabilitation medicine2 (10)
       Physiotherapy3 (15)
       Prosthetics and orthotics1 (5)
       Psychology3 (15)
       Rehabilitation nursing2 (10)
       Speech and language therapy2 (10)
       Other (rehabilitation researcher and service user)1 (5)
      Sex, n (%)
       Female15 (75)
       Male5 (25)
      Location based on WHO world regions, n (%)
       Africa region2 (10)
       Americas region8 (40)
       Eastern Mediterranean region1 (5)
       Southeast Asia region1 (5)
       Western Pacific region3 (15)
      Location based on economic classification, n (%)
       High income countries16 (80)
       Upper-middle income countries3 (15)
       Lower-middle income countries1 (5)
       Low income countries0 (0)

      Identifying the competencies of the RCF: content analysis of existing rehabilitation-related competency frameworks

      A content analysis of existing rehabilitation-related competency frameworks was used given its precedence and recognition as a sound technique for identifying and compiling competency framework statements, particularly when used alongside participatory approaches.
      • Gowie M.
      • Wilson D.
      • Gregory S.
      • Clark L.L.
      Development of a core competency framework for clinical research staff.
      • Julé A.
      • Furtado T.
      • Boggs L.
      • et al.
      Developing a globally applicable evidence-informed competency framework to support capacity strengthening in clinical research.
      • Clements R.
      • Mackenzie R.
      Competence in prehospital care: evolving concepts.
      • Calhoun J.G.D.P.
      • Sinioris M.E.
      • Vincent E.T.
      • Griffith J.R.
      Toward an understanding of competency identification and assessment in health care management.
      In the context of the RCF, it was deemed a practical and strategic methodology to generate an alpha version of the RCF, as it enabled competency statements from all rehabilitation professions and a range of countries to be captured efficiently.
      A database of existing rehabilitation-related competency frameworks was created using REDCap,a a secure web-based software. Identification of frameworks involved a 3-pronged search strategy (search approaches can be found in table 3). First, a call for frameworks was extended to international rehabilitation professional associations, international condition-specific organizations, WHO offices, and academic institutions relevant to rehabilitation for dissemination among their respective networks. Next, a search was conducted using electronic databases (ie, PEDro, OTSeeker, PsychINFO, Cochrane Rehabilitation, MEDLINE, and NHS Evidence). Then, a Googleb search was conducted for competency frameworks related to each of the 8 core rehabilitation professions. For each search, web pages were screened until 2 consecutive pages elicited no more results.
      Table 3Search strategy for the identification of existing rehabilitation-related competency frameworks
      Search Approach 1: Call to International Associations and Organizations
      International professional associations were invited to disseminate the call for frameworksInternational Society of Physical and Rehabilitation Medicine (ISPRM), International Society of Prosthetics and Orthotics (ISPO), International Association of Logopedics and Phoniatrics (IALP), American Speech-Language-Hearing Association (ASHA), World Confederation for Physical Therapy (WCPT), World Federation of Occupational Therapists (WFOT), World Federation of Chiropractic (WFC), International Network of Physiotherapy Regulatory Authorities (INPTRA), International Council of Nurses (ICN)
      International condition-specific organizations were invited to disseminate the call for frameworksCentre for Global Mental Health, World Stroke Organization, World Federation fore Neurorehabilitation (WFNR), World Federation of Neurology, Neuro-Optometric Rehabilitation Association, International Brain Injury Association, Rehabilitation in MS-European Network, Consortium of MS Centers, International Parkinsons and Movement Disorder Society, World Autism Organization, Global Autism Project, International Association for the Scientific Study of Intellectual and Developmental Disabilities, Global Alliance for Musculoskeletal Health, Children's Burn Foundation, International Society for Burn Injuries
      International development organizationsInternational Committee of the Red Cross, Humanity and Inclusion, The ICRC MoveAbility Foundation, Swiss Paraplegic Research
      Research institutionsHannover Medical School, Guttman Institute, Korean National Rehabilitation Research Institute, Korea National Rehabilitation Centre, Tonji Medical College, University of Sydney, WHO Collaborating Centre in Health Workforce Development in Rehabilitation and Long Term Care, General Hospital of the University of Sao Paulo Brazil, WHO Collaborating Centre for Rehabilitation, University of Toronto, University of Cape Town, University of Zimbabwe
      Rehabilitation focal points in WHO officesRegional Office for Africa, Regional Office for the Americas, Regional Office for the Eastern Mediterranean, Regional Office for Europe, Regional Office for South East Asia, Regional Office for the Western Pacific: Tajikistan Country Office, Pakistan Country Office: Cambodian Country Office
      Search Approach 2: Electronic Databases
      DatabaseSearch TermsFilters
      Cochrane RehabilitationCompetenc∗ AND (framework OR model OR standard∗)None
      MEDLINE(Rehabilitation or physiotherapy or "physical therapy" or "occupational therapy" or "speech and language pathology" or "speech and language therapy" or "prosthetics and orthotics" or psychology or audiology) and Competenc∗) and (framework or model or standard∗)Title only
      NHS EvidenceRehabilitation competency framework

      Physiotherapy competency framework

      Occupational therapy competency framework

      Orthotics and prosthetics competency framework

      Speech and language therapy competency framework

      Speech and language pathology competency framework

      Audiology competency framework

      Physiatry competency framework

      Physical medicine and rehabilitation competency framework

      Community rehabilitation competency framework
      Evidence type: Guidance and Policy; practice-based information;

      Area of interest: Clinical;

      Excluded: Guidelines
      OTSeekerCompetenc∗ AND (framework OR model OR standard∗)None
      PEDroCompetenc∗ framework

      Competenc∗ model

      Competenc∗ standard∗
      None
      PsychINFOCompetenc∗ AND (framework OR model OR standard∗)None
      Search Approach 3: Google Search
      Search TermNo. of Pages Searched
      Audiology competency framework, model or standards7
      Community-based rehabilitation or CBR competency framework, model or standards5
      Physical medicine and rehabilitation or physiatry competency framework, model or standards5
      Physiotherapy or physical therapy competency framework, model or standards9
      Prosthetics and orthotics competency framework, model or standards7
      Psychology competency framework, model or standards5
      Rehabilitation nursing competency framework, model or standards4
      Speech and language therapy or speech and language pathology competency framework, model or standards8
      Within the database, key details such as author, field, and year of publication, as well as the thematic structure of the frameworks, were extracted. The thematic structures were reviewed with the TWG, who agreed on 5 domains, each structured to provide the desired level of specificity (fig 1).
      Figure thumbnail gr1
      Fig 1The agreed structure and components of the RCF.
      The content of the existing RCFs was mapped to the 5 domains in a Microsoft Excelc spreadsheet. As content was extracted, it was grouped according to emerging topics such as communication, problem solving, and safety and quality, which shaped the RCF statements. A consultative process between the lead author (J.M.) and the TWG was used to determine how the behaviors and tasks were described across 4 levels of proficiency to capture the scope of performance represented in the rehabilitation workforce (see fig 1). These 4 levels represent an escalation in autonomy and decision making, as well as an increased depth of knowledge and skill mastery, from level 1 to level 4. A profile summarizing the broad expectations of each level was created for each domain. Knowledge and skills, which were poorly described in the identified competency frameworks, were not included in the alpha version of the RCF, and it was determined that a parallel process involving a content analysis of rehabilitation curricula and consultation with condition-specific experts was necessary.

      Relevance and acceptability of the RCF statements to rehabilitation professionals: a modified Delphi study

      A modified-Delphi study was used based on its effectiveness in obtaining consensus in the context of a paucity of empirical evidence, as well as its ability to efficiently and systematically capture the opinions of the broad target audience of the RCF.
      • Farrell P.
      • Scherer K.
      The Delphi technique as a method for selecting criteria to evaluate nursing care.
      • Caves R.
      Consultative methods for extracting expert knowledge about professional competence.
      • Bonner A.
      • Stewardt G.
      Development of competency based standards: an application of the Delphi research technique.
      • Fuller M.
      • Heijne-Penninga M.
      • Kamans E.
      • van Vuuren M.
      • de Jong M.
      • Wolfensberger M.
      Identifying competence characteristics for excellent communication professionals: a work field perspective.
      • Lambert B.
      • Plank R.E.
      • Reid D.
      • Fleming D.
      A competency model for entry level business-to-business services salespeople.
      Delphi studies are among the most commonly used methodologies in the development of competency frameworks, both within and beyond the health sector, and are recognized as a participatory approach that promotes a sense of ownership among the target audience of the framework.
      • Davis R.
      • Turner E.
      • Hicks D.
      • Tipson M.
      Developing an integrated career and competency framework for diabetes nursing.
      ,
      • Hejri S.M.
      • Jalili M.
      Competency frameworks: universal or local.
      A 2-iteration modified Delphi study was undertaken between August 20 and November 20, 2019. The classic Delphi methodology, which uses a structured feedback technique to quantify opinion with the intention of building consensus, was modified to suit the context of the study.
      • Delbecq A.L.
      • Ven de Ven A.H.
      • Gustafson D.H.
      Group techniques for program planning: a guide to nominal group and Delphi processes.
      ,
      • McKenna H.P.
      The Delphi technique: a worthwhile research approach for nursing?.
      Rather than requesting participants to rank or prioritize statements in the RCF, the modified Delphi study used binary responses (agree/disagree) to determine whether the statements should be included or not, and free text fields to identify what adjustments were needed to achieve optimal consensus. Ranking and prioritization of statements was not considered meaningful as they are complimentary and equally weighted in the RCF, and the binary response options eliminated the generation of superfluous data and increased the speed with which participants could move through the questionnaires, which was important given their length. Participants were also given the option to opt out of responding to a specific statement if they felt unable to comment on the subject area. Furthermore, unlike the traditional Delphi study technique, the study commenced with an existing draft framework (the alpha draft), rather than using an initial round of open-ended questions to generate content. It was decided that, given the scope of the framework, it was more efficient to develop the alpha version through the content analysis, as described above.
      Participants were identified via nomination by the TWG. Nominees were screened according to their world region and profession, and a selection was made that attempted to achieve the best possible representation of low- and middle-income countries and a balance between professions. All participants who had commenced the first iteration of the study were invited to participate in the second, regardless of how far they had progressed.
      The online questionnaire instruments were created using REDCap and were disseminated via e-mail. Each iteration included 2 versions of the questionnaire that ordered the statements in a different sequence to avoid response fatigue affecting some more than others, although the statements from the Practice and Professionalism domains were always the first to be presented. Participants were given 1 month to complete each iteration of the study, with a 1-month gap between iterations. Weekly reminders were sent to encourage completion. Participants were not offered incentives for completing the questionnaires, with the exception of a certificate and acknowledgment within the published RCF.
      Data were analyzed using SPSS.d According to the study protocol, statements with less than 90% agreement were to be revised. However, all recommendations were considered regardless of the rate of agreement. Results of each iteration were used to amend the RCF statements, with changes proposed by the lead author (J.M.) in consultation with the TWG, in response to the qualitative and quantitative data produced.

      Relevance and acceptability of the competencies to rehabilitation service users: a questionnaire-based consultation

      Although content analyses and Delphi studies are widely used in the development of competency frameworks, consumer consultations are less common. This is owing in part to the fact that consumers can generally offer opinion only on certain nontechnical aspects of performance, and thus can speak only to a restricted portion of competency framework content. However, given that rehabilitation practice is highly collaborative and that positive therapeutic relationships greatly affect outcomes, it was decided that consumer opinion should be sought on the core values and beliefs of the RCF, as well as selection of competencies and behaviors that were directly related to interpersonal interaction and decision making. Given the scope of the RCF and its intention for global application, an online questionnaire was selected as the mode by which to gather rehabilitation service user opinions, with a view to conduct interviews if the findings were ambiguous or highly disparate.
      The rehabilitation service user consultation used a questionnaire instrument in both English and French, generated using REDCap. Participants were identified using a snowballing method: the TWG nominated 26 rehabilitation services from 13 countries that could disseminate the questionnaire to suitable service users and to other rehabilitation services, which could do the same. The questionnaire was also disseminated to 13 organizations representing rehabilitation services users and was promoted on the website of the WHO Global Cooperation on Assistive Technology community. No rehabilitation service users were directly contacted by the study coordinators.
      The questionnaire used Likert scales and free text fields to determine participants’ agreement with and opinions regarding the RCF values and beliefs statements, as well as competencies and behaviors concerning client-centeredness, working relationships, client engagement, communication, professional integrity, contextual consideration, and advocacy. The questionnaire remained open for 6 weeks between September and November 2019. Qualitative results were analyzed using NVivo 12e (responses in French were translated to English), and quantitative responses were analyzed using Microsoft Excel. Results of the consultation were considered along with those of the final iteration of the modified Delphi study and were used by the lead author and TWG to make final amendments to the RCF statements. Given the broad agreement indicated by the questionnaire results, it was decided not to proceed with additional interviews.

      Results

      Content analysis of existing rehabilitation-related competency frameworks

      The TWG agreed on 5 RCF domains: Practice, Professionalism, Learning and Development, Management and Leadership, and Research. Content extraction from the existing rehabilitation-related competency frameworks resulted in an alpha version of the framework that included 17 competencies and 47 associated behaviors relevant to all rehabilitation professionals, and 22 activities, encompassing 52 tasks and covering a broad scope of rehabilitation practice, across the domains. Four core values and 3 core beliefs were included.

      Modified Delphi study

      A selection of 165 individuals were invited to participate in the modified Delphi study, including the 20 members of the TWG. Of these, 84 (51%) completed at least 1 section of the first iteration questionnaire, although only 77 (47%) completed all sections. A total of 102 individuals (those who had commenced the previous iteration, regardless of completion) were invited to participate in the second iteration questionnaire, 71 (70%) of whom completed at least 1 section, and 68 (67%) completed all sections. Demographics for the participants for each iteration can be found in table 4.
      Table 4Demographics of modified Delphi study participants
      VariableFrequency, n (%)
      Round 1Round 2
      Profession
      Professions and roles were not mutually exclusive. Most participants had only 1 profession, but many held multiple roles.
       Audiology7 (8)7 (10)
       Occupational therapy19 (23)16 (23)
       Physical and rehabilitation medicine12 (14)11 (15)
       Physiotherapy23 (27)18 (25)
       Prosthetics and orthotics6 (7)4 (6)
       Psychology10 (12)7 (10)
       Rehabilitation nursing9 (11)8 (11)
       Speech and language therapy6 (7)9 (13)
       Other8 (10)6 (8)
       None1 (1)0 (0)
      Role
      Professions and roles were not mutually exclusive. Most participants had only 1 profession, but many held multiple roles.
       Educator47 (56)45 (63)
       Manager24 (29)22 (31)
       Practitioner41 (48)36 (51)
       Policy maker9 (11)8 (11)
       Researcher43 (51)38 (54)
       Service developer24 (29)21 (30)
      Level of education
       High school0 (0)0 (0)
       Certificate or diploma2 (2)2 (3)
       Undergraduate degree10 (12)7 (10)
       Postgraduate degree72 (86)62 (87)
      Sex
       Female62 (74)52 (73)
       Male22 (26)19 (27)
      Age category
       20-30 y6 (7)3 (4)
       31-40 y16 (19)13 (18)
       41-50 y18 (21)15 (21)
       >50 y44 (52)40 (56)
      Professions and roles were not mutually exclusive. Most participants had only 1 profession, but many held multiple roles.

      Results of first iteration of the modified Delphi study

      The first iteration of the modified Delphi study revealed an average agreement of 95% with statements across all domains and a total of 983 comments and recommendations (fig 2). Responses highlighted the need for adjustments to how some behaviors and tasks were described across the 4 levels of proficiency, providing greater clarity on the distinction between behaviors or tasks, as well as modifications to how some statements were expressed. It was evident from comments and recommendations that many participants did not recognize that certain activities and tasks are not relevant to all rehabilitation professionals, that proficiency levels do not align to specific cadres, and that individual professionals may align with different levels of proficiency in different domains and over time. This led to the second iteration questionnaire including further explanation of these points and more frequent prompts for their consideration. The results revealed less than 90% agreement on 14% of the statements (see fig 2). Despite the high degree of agreement, all statements underwent some degree of revision following comments owing to their interconnected nature.
      Figure thumbnail gr2
      Fig 2Level of participant agreement and number of comments and recommendations in the first and second iterations of the modified Delphi study.

      Results of second iteration of the modified Delphi study

      The average participant agreement increased to 95% across all domains in the second iteration, and the total number of comments and recommendations was reduced by 56% to 428 (see fig 2). One task in the Practice domain received less than 90% agreement (87%). This task related to the use of pharmacologic agents, and the corresponding comments and recommendation suggested that some who disagreed did not realize that the task was not relevant to all rehabilitation professionals. Following comments and suggestions, several changes were made to behaviors and tasks to reduce ambiguity or duplication, but most competencies and activities remained the same.

      Rehabilitation service user consultation

      A total of 36 individuals participated in the rehabilitation service user consultation, with 30 completing all sections (23 used the English version, 7 used the French version). The largest representation (44%) was from European countries and aged between 35 and 55 years (50%). None of the individuals were younger than 18 years of age. Collectively, the participants had encountered all of the core rehabilitation professions and received rehabilitation in all settings (see table 5 for a full list of demographic characteristics). Among the sample, spinal cord injury, fracture, lower back pain, vision impairment, and hearing impairment were the most commonly reported health conditions for which the participants had sought rehabilitation (fig 3).
      Table 5Demographics of rehabilitation service user consultation
      VariableFrequency, n %
      Age
       <18 y0 (0)
       18-24 y6 (17)
       25-34 y3 (8)
       35-44 y8 (22)
       45-55 y10 (28)
       55-64 y6 (17)
       >64 y3 (8)
      Sex
       Female19 (53)
       Male17 (49)
      Setting in which rehabilitation occurred
      Participants may have received rehabilitation in multiple settings and encountered multiple professions.
       Community setting (home, school, workplace)11 (31)
       General hospital13 (36)
       Rehabilitation practice20 (56)
      Professions encountered
      Participants may have received rehabilitation in multiple settings and encountered multiple professions.
       Audiologist5 (14)
       Community-based rehabilitation worker5 (14)
       Occupational therapist8 (22)
       Physiotherapist21 (58)
       Physical and rehabilitation medicine doctor5 (14)
       Prosthetist and orthotist2 (6)
       Psychologist5 (14)
       Rehabilitation nurse5 (14)
       Speech and language therapist5 (14)
       Other4 (11)
      Participants may have received rehabilitation in multiple settings and encountered multiple professions.
      Figure thumbnail gr3
      Fig 3Frequency of health conditions for which the service user sample sought rehabilitation.

      Results of quantitative responses from the service user consultation

      There was an average 87% agreement with the statements for core values and beliefs of the RCF, as well as with the select competency statements that were included in the consultation (fig 4). Similarly, 80% strongly agreed with the selected behavior statements (fig 5). No justifications were provided for disagreement, nor were specific critiques made in conjunction with the responses of “Somewhat agree.”
      Figure thumbnail gr4
      Fig 4Average level of agreement by the rehabilitation service user sample with core values and belief and select Practice and Professionalism competencies.
      Figure thumbnail gr5
      Fig 5Average level of agreement by the rehabilitation service user sample with select Practice and Professionalism behaviors.

      Results of qualitative responses from the service user consultation

      Several themes and subthemes emerged from the free text feedback received in the service user consultation (table 6). It was apparent that the RCF captures what is important to rehabilitation service users. However, the collaborative nature of rehabilitation was deemed not sufficiently clear and an additional core belief was added to the RCF to rectify this. The need for rehabilitation professionals to have the knowledge and skills necessary to provide quality care was the most frequently noted theme in service user feedback, rating 25% higher than the need to engage the individual and his or her family in practice and communication, which were the next most frequently referenced themes.
      Table 6Frequent themes in rehabilitation service user consultation responses
      Theme (Key Subthemes)Reference FrequencyLocation Where Addressed in the RCF (Topic)
      Practice capability (including “experienced,” “knowledgeable,” and “skilled”)33Crosscutting
      Engaging the person (including involving the family,” “listening to the person,” and “being person-centered”)25Core beliefs

      Practice competency 1 (person-centered practice)

      Practice behavior 1.1 (active participation)

      Practice competency 2 (collaborative relationship)

      Practice behavior 3.4 (active listening)
      Communication24Practice competency 3 (communication)
      Taking a holistic approach (including “valuing well-being,” “considering the context,” and “considering the whole person”)15Core beliefs

      Practice behavior 4.1 (personal, environmental, and health factors)
      Empathy15Core values
      Professionalism (including “commitment and dedication,” “confidence,” and “respect”)13Core values

      Professionalism competency 2 (professionalism) Professionalism behavior 2.1 (instilling confidence) Professionalism competency 4 (managing responsibilities)
      Being approachable (including “kindness”)10Core values

      Practice behavior 2.1 (positive rapport)
      Being inclusive9Core beliefs

      Practice behavior 1.2 (adapting practice)
      Adopting a human rights approach8Core beliefs
      Nondiscrimination6Core values
      Cultural awareness4Practice behavior 2.4 (attitudes, beliefs, and feelings)
      Empowering the person4Core values

      Practice behavior 1.1 (active participation)
      After all changes from the modified Delphi study and service user consultation were implemented, the number of RCF core beliefs increased to 4, behaviors to 56, and tasks to 62. The number of activities was reduced to 20, whereas the number of competencies remained at 17 and core values at 4 (see RCF webpage: www.who.int/teams/noncommunicable-diseases/disability-and-rehabilitation/rehabilitation-competency-framework).

      Discussion

      This study presents the mixed methods used to develop and validate the RCF. The methodologies applied reflected best practice in competency framework development, notably drawing from multiple sources of data and applying a highly participatory, staged approach that gathered and built on the consensus of the target population.
      • Farrell P.
      • Scherer K.
      The Delphi technique as a method for selecting criteria to evaluate nursing care.
      ,
      • Bonner A.
      • Stewardt G.
      Development of competency based standards: an application of the Delphi research technique.
      ,
      • Davis R.
      • Turner E.
      • Hicks D.
      • Tipson M.
      Developing an integrated career and competency framework for diabetes nursing.
      ,
      • Hejri S.M.
      • Jalili M.
      Competency frameworks: universal or local.
      ,
      • Campion M.A.
      • Fink A.A.
      • Ruggeberg B.J.
      • Carr L.
      • Phillips G.M.
      • Odman R.B.
      Doing competecies well: best practices in competency modeling.
      Focus groups and traditional job analysis, which are also frequently used, were not considered a feasible methodology for this study given the multiple professions and specializations the RCF encompasses and its global scope, and have been criticized as time and resource intensive.
      • Davis R.
      • Turner E.
      • Hicks D.
      • Tipson M.
      Developing an integrated career and competency framework for diabetes nursing.
      ,
      • Campion M.A.
      • Fink A.A.
      • Ruggeberg B.J.
      • Carr L.
      • Phillips G.M.
      • Odman R.B.
      Doing competecies well: best practices in competency modeling.
      Using desk-based methods that used online research and questionnaires allowed the authors to achieve greater coverage of the target population of the framework within the time and resource constraints of the project. Indeed, the strength of using the mixed methods was the ability to capture content, opinions, and perspectives from a broad range of frameworks, professional groups, and individuals from around the world. This was fundamental given the intention of the RCF to be a globally relevant tool for the various professions and specializations comprising the rehabilitation community.
      Perhaps the most significant finding of the mixed methods study was the confirmation that it is possible to compile the values, beliefs, competencies, behaviors, activities, and tasks of multiple professions and specializations within the rehabilitation field in a shared competency framework. The RCF demonstrates that the rehabilitation activities and tasks involved in the scope of rehabilitation practice, although not necessarily performed by all rehabilitation professionals, can be captured in a single organizational structure, and that core values, beliefs, competencies, and behaviors are shared across the range of work undertaken.
      It is important to recognize that addressing rehabilitation professional performance is necessary but not sufficient to address the challenges faced by the rehabilitation workforce.
      • Kuchinke K.P.
      • Han H.-Y.
      Should caring be viewed as a competence? (Re-)opening the dialogue over the limitations of competency frameworks in HRD.
      ,
      • Munro A.
      • Andrews B.
      Competences: dialogue without a plot? Providing context through business diagnostics.
      Rehabilitation professionals train and work within systems and environments that are key determinants for their performance and the subsequent outcomes of their interventions. The positive effects of the rehabilitation workforce on population functioning can only be realized when issues of governance, financing, assistive technology, information systems, and service delivery are simultaneously addressed. Indeed, although the effects of rehabilitation workforce challenges manifest as deficiencies in frontline care, they are symptomatic of underlying system failures.
      • Jesus T.S.
      • Hoenig H.
      Crossing the global quality chasm in health care: where does rehabilitation stand?.
      ,
      National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Board on Global Health
      Committee on Improving the Quality of Health Care Globally. Crossing the global quality chasm: improving health care worldwide.
      Nevertheless, in drawing the rehabilitation community into a single framework, the RCF serves to strengthen its unity, which is critical to it gaining the power required to expand at the systems-level. Furthermore, it provides a tool to facilitate competency-based approaches to education and training, regulation, service planning, and human resource management, which help ensure that the rehabilitation workforce is aligned with population needs and the delivery of high quality care.

      Study limitations

      The development process of the RCF has several limitations of note. Despite best efforts, certain world regions, specifically the Eastern Mediterranean and Southeast Asian regions, as well as low-income countries, were underrepresented among the participants of both the modified Delphi study and rehabilitation service user consultation. There was not an equal balance among other demographic variables for the modified Delphi study, such as sex, age, and profession, which may have affected results. The absence of participants younger than 18 years of age in the rehabilitation service user consultation also meant that the views of children, who are key beneficiaries of rehabilitation, were not captured. The TWG, which is composed of professionals from all disciplines and world regions and with experience across different areas of rehabilitation practice, including pediatrics, helped to mitigate the risks introduced by such imbalances.
      As a result of funding restrictions, the questionnaires were only made available in English and, for the rehabilitation service user consultation, in French. This may have prohibited potential participants from engaging in the studies or from fully expressing their views in the free text fields of the questionnaires.

      Conclusions

      This study conceives of the RCF as a sociotechnical tool that both facilitates communication and rehabilitation workforce capability, while unifying a historically fragmented field under a shared framework. The interdisciplinary collaboration demonstrated in this mixed methods study bodes well for the rehabilitation workforce, indicating its potential to achieve the political maturity and recognition it needs to strengthen rehabilitation capacity in health systems.

      Suppliers

      • a.
        REDCap; Vanderbilt University.
      • b.
        Google Search; Google, LLC.
      • c.
        Excel; Microsoft Corp.
      • d.
        SPSS; IBM Corp.
      • e.
        NVivo 12; QSR International.

      Acknowledgments

      We thank the Rehabilitation Competency Framework Technical Working Group for their guidance and input to the development of the Framework. We also thank Pauline Kleinitz, MSc, Elanie Marks, MSc, and Alexandra Rauch, PhD, for their valuable comments and suggestions to the development of the Rehabilitation Competency Framework.

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