Appendix

Dr. Sue Bookey-Bassett; Dr. Sherry Espin; and Sukhanjit Kaur

Theoretical Underpinnings and Competency Frameworks

The Competency Framework for High-Quality Workforce Development in Integrated Care by Barraclough et al. (2024)

This framework presents competencies to guide education facilities, workplaces, and accreditation in creating a trained workforce in integrated care.

Table 1.

Competency Framework for High-Quality Workforce Development in Integrated Care (2024).

Competencies Team members should be able to…
Person-centered care: teams place individuals and their support networks at the center of care planning and delivery.
  • Promote shared identification of strengths and have a comprehensive understanding of the individuals’ needs.
  • Increase individuals’ and caregivers’ knowledge, skills and confidence in navigating the health and social care system.
  • Empower individuals to participate in their own care.
  • Actively involve and support caregivers and respond to signs of caregiver distress.
Interprofessional teamwork and collaborative practice: team members work effectively across multiple disciplines, care settings, and services to provide high-quality, coordinated care.
  • Work effectively in teams across disciplines and settings.
  • Collaborate with service providers within the acute, primary, and informal care sectors.
  • Share information and data across teams, service providers, and individuals and their families.
  • Demonstrate well-developed negotiation skills.
Care coordination: team members organize and integrate care across multiple services.
  • Adopt a care coordinator role and emphasize effective communication.
  • Demonstrate the ability to effectively coordinate care within a complex system.
  • Demonstrate knowledge of local and national policies and programs, and communicate them to others.
  • Identify and collaborate with a range of professionals.
Digital skills and technology: team members should have digital literacy and technological proficiency.
  • Engage patients and families through technology-based communication tools.
  • Use a range of technology.
  • Utilize linked datasets and population health management tools to analyze data and identify trends to inform and evaluate integrated care.
  • Using shared electronic patient records to enhance communication and collaboration.
Health promotion and disease prevention: team members empower individuals, families and communities to make informed decisions that support overall wellbeing.
  • Facilitate behaviour change among individuals, families, and communities to promote health, resilience, wellbeing, and disease prevention.
  • Obtain an integrative and comprehensive history.
  • Have knowledge of community resources and preventative programs.
  • Provide education on self-care strategies and resources, and incorporate them into all care plans.
Population health approach to care: team members use a population health approach to improve community health.
  • Identify and address community needs by understanding available resources, population data, and gaps in healthcare delivery.
  • Demonstrate knowledge of population health strategies and programs.
  • Understand how to navigate the system.
  • Identify and refer vulnerable populations and those experiencing health inequalities to appropriate support programs.
  • Understand the social determinants of health and their impact on population health.
Leadership: team members guide change, promote collaboration, and create environments that support person-centered, system-wide improvements.
  • Develop as leaders and role models to advocate for and support the implementation of integrated care.
  • Demonstrate leadership in person-centred and collaborative practice.
  • Implement shared governance across multiple stakeholders and sectors.
  • Work with service providers and people with lived experience and use research methods to drive change and improve services.
Professional and ethical attributes: team members model integrity and ethical behaviour with a commitment to self-awareness, continuous growth, and inclusive, compassionate practice
  • Demonstrate the following professional and ethical practitioner attributes:
    • Practicing and integrating self-care strategies
    • Engaging in continuous learning, supervision and maintaining evidence-informed practice
    • Becoming mentors, teachers and peer learners
    • Showing empathy and emotional intelligence
    • Practicing reflective thinking and learning
    • Demonstrating competencies in working with differences (cultural, social and neurodiversity).

The World Health Organization Rehabilitation Competency Framework (2021)

The World Health Organization (WHO) created a competency framework for rehabilitation in 2021 for all rehabilitation workers, comprised of five overarching domains. These domains include practice, professionalism, learning and development, management and leadership, and research. The framework also contains the associated activities for each competency. Please refer to the competency framework document for the different levels of mastery of each competency or activity, along with the core knowledge for each competency.

Table 2.

Key takeaways from the World Health Organization Rehabilitation Competency Framework (2021).

Domain  Competencies – The worker: Activities – Activities include:
Practice 
  • Places the person and their family at the center of practice.
  • Establishes a collaborative relationship with the person and their family.
  • Communicates effectively with the person, their family, and their health-care team.
  • Adopts a rigorous approach to problem-solving and decision-making.
  • Works within their scope of practice and competence.
  • Obtaining informed consent for rehabilitation
  • Documenting information
  • Conducting rehabilitation assessments
  • Developing and adapting rehabilitation plans
  • Referring to other providers
  • Implementing rehabilitation interventions
  • Evaluating progress towards desired outcomes
  • Discharging and ensuring appropriate continuity of care
Professionalism 
  • Demonstrates ethical conduct
  • Maintains professionalism
  • Works collaboratively
  • Manages professional responsibilities
  • Managing risks and hazards
  • Undertaking quality improvement initiatives
  • Participating in team forums
  • Advising on rehabilitation
Learning and Development 
  • Continues to learn and develop
  • Supports the learning and development of others
  • Works to strengthen rehabilitation education and training
  • Managing own professional development
  • Supervising and teaching others
Management and Leadership 
  • Works to enhance the performance of the rehabilitation team
  • Works to enhance the performance of rehabilitation service delivery
  • Acts as a rehabilitation advocate
  • Managing a rehabilitation team
  • Managing rehabilitation service delivery
  • Monitoring and evaluating rehabilitation service delivery
Research 
  • Integrates evidence in practice
  • Works to strengthen evidence for rehabilitation
  • Designing and implementing research
  • Disseminating evidence
  • Strengthening rehabilitation research capacity

The Stroke Specific Education Framework by the University of Central Lancashire and the National Health Service in England (2022).

The framework for stroke-specific education, created by the University of Central Lancashire and the National Health Service of England (2022), outlines the knowledge and skills required by those caring for people with stroke or affected by stroke. This framework comprises 16 elements of care and 4 elements of professional practice.

For the purposes of this learning experience, please refer to “Element 10: Specialist rehabilitation”, “Element 12: Seamless transfer of care”, “Element 13: Long term care”, “Element 14: Review”, “Element 15: Participation in community”, “Element 16: Return to work”, “Element 17: Professional behaviour and values”, “Element 18: Leadership, management, and governance”, and “Element 19: Education, training, and personal development”. Please visit the website for the framework for more in-depth information under each element.

Table 3.

Key takeaways from the Stroke Specific Education Framework (2022).

Element Required knowledge  Required skills
Element 10: Specialist Rehabilitation

Stroke survivors access rehabilitation services, and survivors and their caregivers require high-quality, stroke-skilled services as soon as possible in all 3 phases, including within the hospital, immediately following transfer, and for as long as required thereafter.
  • The range of potential impacts of stroke on individuals and their families, including psychological, social, physiological, sensory, neurological and neuropsychological effects
  • The cause of, interactions between, assessment of, management of, and treatment of the above impacts.
  • Principles and techniques of multidisciplinary stroke assessment and rehabilitation
  • Screening measures
  • Safe moving, handling and positioning
  • Ways to facilitate communication
  • Health promotion approaches
  • Ways to enable those affected by stroke to take an active role in recovery
  • Pharmacological and non-pharmacological interventions and secondary prevention
  • Full range of resources
  • Equipment and technology
  • Implications of stroke on lifestyle
  • Transfer/discharge process, long-term management and rehabilitation
  • Collect and interpret a thorough medical history
  • Recognize the signs and symptoms related to the impacts of stroke
  • Determine, plan and initiate the appropriate assessments, investigations, interventions and treatments
    • Use a range of communication methods, resources and approaches
  • Provide a psychologically-informed, patient-centred assessment, formulation and intervention
  • Use safe moving, handling and positioning methods
  • Provide a range of stroke-specialist rehabilitation techniques and the clinical rationale for the chosen technique
  • Assist in the management and development of a behaviour change plan that is patient-centered.
  • Assist, encourage, and facilitate post-stroke physical, social, and cultural reintegration
  • Identify and refer to appropriate resources
  • Identify the need and when to refer individuals to specialist treatments
Element 12: Seamless transfer of care

A workable, clear, and patient- and caregiver-centered discharge plan is developed by the multidisciplinary team with other services such as transport and housing.
  • Assessment and management of the effects of stroke to identify care and ongoing rehabilitation needs
  • Implications of stroke for lifestyle, driving, occupation, including voluntary work or education, and social participation
  • The range of local and national resources and services for stroke survivors, especially for:
    • Transfer
    • Short and long-term needs assessment
    • Packages of care
    • Continued rehabilitation and psychological care
    • Finance and personal budgets
    • Respite care
  • Principles of good discharge planning for transition between services, cessation of services, and for transfer of care to the community, including education for those impacted by stroke
  • Principles of multi-agency working
  • Determine, plan, and initiate appropriate assessments, including risk assessments, to determine care and support needs on discharge, and minimize risk
  • Assess, discuss, and review goals, outcomes, and a discharge plan
  • Identify the need for and when to refer for specialist or differing treatment
  • Identify resources and services to overcome barriers and facilitate effective and efficient discharge for those affected by stroke
Element 13: Long-term care

A range of services are in place and easily accessible to support the individual long-term needs of those affected by stroke.
  • The assessment and management of the effects of stroke to inform long-term care
  • The impacts of stroke on survivors and their caregivers, and assessment methods
  • Implications of stroke on lifestyle, driving, occupation, and social participation
  • Risk factors for further vascular events
  • Pharmacological and non-pharmacological interventions for secondary stroke prevention and to promote recovery after stroke, and their potential adverse effects
  • Resources and services relating to long-term care, housing, transport, adjustments, and supporting independent living when possible
  • Communication methods
  • Assessments of medication adherence, factors that impact it and how to motivate and facilitate engagement
  • Recognize stroke-related communication difficulties and adapt communication methods.
  • Discuss current events, risk of future events, need for and timeframe of assessments, rationale for interventions and treatments, timeframes, and possible side effects
  • provide timely information, advice and support
  • Monitor progress and modify plan on an ongoing basis
  • Assess, discuss and review goal-setting and outcomes with those impacted by stroke
  • Identify resources and services to support long-term care needs; liaise with services; work across agencies; share information; and communicate referral arrangements.
  • Assess post-stroke apathy and readiness for behaviour modification and support change
  • Deliver and evaluate self-management programs.
Element 14: Review

The primary care service offers those affected by stroke a review of their health and social care status, as well as their secondary prevention needs.
  • The assessment and management of the effects of stroke
  • Ways to assess and meet the needs of those affected by stroke
  • Available resources and services
  • Implications of stroke on lifestyle
  • Risk of further vascular events
  • Pharmacological and non-pharmacological interventions for secondary prevention and to promote recovery, and their potential adverse effects
  • The methods, resources, and approaches available to facilitate communication
  • Medication adherence, factors that impact it and how to motivate and facilitate engagement
  • Take and interpret a thorough medical history from all stakeholders and carry out decision-specific mental capacity assessments
  • Recognize stroke-related communication difficulties and adapt communication methods.
  • Discuss the current event, risk of future events, rationale for interventions and treatments, timeframes, and possible side effects
  • provide timely information, advice and support
  • Monitor progress and modify plan on an ongoing basis
  • Assess, discuss and review goal-setting and outcomes with those impacted by stroke
  • Assess medication adherence and facilitate improved engagement
  • Plan appropriate assessments and treatments
  • Identify the need for additional/specialty/differing interventions/referrals
  • Evaluate the review process and act on results
Element 15: Participation in community

Those affected by stroke are enabled to live a full life in the community.
  • The assessment and management of the effects of stroke and their impact on community participation
  • Local and national resources/services for those with stroke, especially those relating to community participation
  • The need for and method of assessment of those impacted by stroke
  • Implication of stroke for lifestyle
  • The methods, resources and approaches available to facilitate communication with those affected by stroke
  • Assess, discuss and review goal-setting and outcomes
  • Monitor progress on and modify the plan with those affected by stroke
  • Plan appropriate assessments and treatments for community participation
  • Identify the need for and when to refer for more specialist or differing treatments
  • Identify the full range of local and national resources to facilitate participation and inclusion
Element 16: Return to work 

Those affected by stroke are enabled to participate in paid, supported, and voluntary employment.
  • The effects of stroke and how they may affect return to work or education
  • How to assess and manage the impact of stroke
  • Legislation on employment, discrimination and health and safety at work
  • The role of healthcare professionals in vocational rehabilitation
  • The resources and services available to those affected by stroke
  • The meaning of “reasonable adjustment” in the workplace, how to adapt to the work environment, and the employer’s responsibility
  • Available technology to assist with functional and activity limitations
  • Ergonomic principles
  • Accessibility issues and solutions
  • The relationship between meaningful engagement in occupation and health and well-being
  • Benefits in relation to occupation, including voluntary work and education
  • Workplace assessment, including risk, job analysis, return to work planning and job retention
  • Models of vocational rehabilitation and vocational case management
  • Vocational rehabilitation guidelines and standards
  • Refer to a vocational rehabilitation service
  • Identify resources and services available to support return to work or education for those affected by stroke, liaise, and communicate with all involved parties
  • Assess for, advise on, and review the need for workplace adaptation, assistive technology and environmental adaptations to overcome work-related activity limitations.
  • Create a personalized plan for return to occupation
  • Advise employers, colleagues and educators about the effects of stroke and negotiate a plan of return to work/education
  • Recognize the need for benefits, advise and refer
  • Conduct or refer for a workplace assessment and risk assessment
  • Set goals for return to or retention of work
  • Case manage or refer for case management
  • Implement vocational rehabilitation guidelines
Element 17: Professional Behaviour and Values

Staff understand how to conduct themselves professionally at all times, in accordance with working guidelines, communicate effectively, and work collaboratively.
  • Abilities and developmental needs to deliver evidence-based care
  • Barriers to effective professional communication and different communication strategies and tools to improve communication.
  • The code of professional conduct
  • Policies that guide professional practice, service improvement and research
  • Person-centered and values-based care
  • Methods of implementing behaviour change interventions
  • Evidence-based practice and  the roles of applied health and social care
  • The roles of and interplay between multi-disciplinary team members and the wider team
  • working in partnership with individuals, families, caregivers, and stakeholders
  • factors contributing to workplace stress and ways to promote mental health and wellbeing, emotional intelligence, and improved resilience
  • the principles of time management and workload planning
  • Demonstrate self-reflection and identify developmental needs
  • Articulate opinions in a clear, evidence-based manner, and communicate complex information effectively
  • Practice according to the code of conduct
  • Practice person-centered and values-based care to support decision-making and care planning.
  • Exercise professional expertise and judgement for ethical decision making and complexity management within the scope of practice, ensuring the safety of all.
  • Use evidence in practice.
  • Act as a role model
  • Demonstrate understanding of responsibility and autonomy, and acknowledge limitations of own competence and professional scope of practice
  • Build professional working relationships with colleagues to work effectively in the multi-disciplinary team.
  • Identify when there is a requirement to breach confidentiality, when legal advice is required, and when to escalate to a senior clinician
  • Demonstrate digital literacy
Element 19: Education, training, and personal development

Staff understand the importance of lifelong learning for the individual, the team, and their patients, and continually take opportunities to engage in and encourage education.
  • Importance of continued development
  • The role of critical self-reflection in personal development and regular assessments of learning needs
  • How to create an effective learning environment
  • Theories underpinning clinical education and mentorship
  • The theory of evidence-based practice and the role of research-informed teaching
  • Assessment and evaluation methods
  • Knowledge mobilization and capacity building
  • Show a positive attitude to practice, learn and self-develop
  • Undertake a personal learning needs assessment, demonstrate critical self-reflection, set goals and develop a learning plan
  • Contribute to and promote the professional development of others
  • Teach others
  • Devise and deliver research-informed learning
  • Promote learning and create a supportive and engaging learning environment
  • Provide constructive, informative, and factual feedback

Kolb’s Theory of Experiential Learning

Kolb’s (1984) theory of experiential learning builds on the ideas of John Dewey (1938), who posits that education is grounded in experience and that learning occurs through the reconstruction of and critical reflection on those experiences (Kreber, 2001). Kolb’s (1984) theory argues that knowledge is created through the transformation of experience and that learning is experiential only when an experience is transformed into knowledge (Kreber, 2001). For experiential learning to occur, students must be directly involved in it (Kolb, 1984; Kreber, 2001). This engagement can occur through action or reflection, which allows the transformation of knowledge to occur (Kreber, 2001). Figure 1 shows Kolb’s 1984 (as represented in Kreber, 2001) model of experiential learning, which contains two dimensions:

  • Prehension of experience – this dimension explains how students grasp experiences through either apprehension (felt qualities; includes intuitive, creative and tacit knowledge) or comprehension (conceptual interpretation and symbolic representation).
    • Concrete experience – this is a direct, sensory and intuitive engagement with the learning experience and is related to apprehension
    • Abstract conceptualization – this is the analytical or symbolic understanding of material related to comprehension
  • Transformation of experience – this dimension explains how experiences are processed and how learning occurs. Learning occurs when an experience is transformed through internal reflection on the learning event or actively manipulating the outside world.
    • Reflective observation – related to internal reflection and is achieved through thoughtful review.
    • Active experimentation – related to active manipulation of the outside world or practical application.

These dimensions combine into a four-stage learning cycle

  • Concrete experience – an encounter with the new experience or situation
  • Reflective observation – thoughtful observation and reflection on the experience
  • Abstract conceptualization – forming theories or models based on reflection
  • Active experimentation – testing new theories through actions

Types of knowledge resulting from the intersection of the two dimensions:

  • Divergent knowledge: a result of apprehension and reflective observation.
  • Assimilative knowledge: a result of comprehension and reflective observation.
  • Accommodative knowledge: a result of apprehension and active experimentation.
  • Convergent knowledge: a result of comprehension and active experimentation.

Meaningful learning occurs when learners work through all four phases of the learning cycle.

 

In this activity, the journey map represents the abstract conceptualization and is meant to help contextualize the concrete experience students may not have had yet, as well as support reflective observation on experiences of patient and caregiver journeys they might have gained in other contexts of their studies or even lived experiences beyond school (Kreber, 2001). One important consideration the developers want to point out is that the linear abstraction of phases of care could be seen as both a valuable way of approaching designing and delivering services and supports, but also as potentially harmful in the ways they might permit lapses in service and support between transition points, that is, without intentional and supportive service integration considered from the outset. During this activity, students will be provided with information through narrative vignettes, written information from focus groups with experts, and case studies, which help provide context for the experiences that students will engage with in the future (Kreber, 2001). Students will process information on an emotional and intuitive level, and information will take hold based on how it feels to them (Kreber, 2001).

 

These narratives are organized into a journey map comprising three commonly experienced phases of the stroke journey, and include points of transition between phases (Kreber, 2001). The instructors will facilitate the progression through this journey map. They will ask questions to help students distinguish key concepts within and between the narratives and phases. This enables symbolic and analytical comprehension of concepts, thereby facilitating abstract conceptualization (Kreber, 2001).

 

To help students transform knowledge and for learning to occur, facilitators will pose critical reflective questions throughout the different stages of the activity to promote reflective observation, internal reflection and thoughtful review (Kreber, 2001). These questions will ask students to think creatively about how to solve the problems posed. Students will then be asked to relate the knowledge they have gained to previous experiences and to hypothetical situations through the debriefing activities and the final evaluation activity. This will facilitate active experimentation with newly acquired knowledge (Kreber, 2001).

The Canadian Interprofessional Health Collaborative Competency Framework for Advancing Collaboration (2024)

The Canadian Interprofessional Health Collaborative (CIHC) Framework (2024) guides educators, researchers, health administrators, service providers, and persons receiving care in fostering effective collaborative practice by focusing on supporting the application of knowledge, skills, attitudes, and values in real-world environments to guide behaviours that enhance collaboration. The framework has six competency domains, which are interdependent.

 

The overarching goal of this framework is to improve healthcare and human services by promoting collaborative, relationship-focused partnerships for shared decision-making.

 

Domain Description
Relationship-Focused Care/Services Team members collaborate and coordinate the building of purposeful, inclusive, culturally safe, respectful and trusting relationships in care and service delivery.
Team Communication Team members promote clear, responsive, respectful, effective, and inclusive communication among team members through shared language, active listening, removing barriers to communication and documentation.
Role Clarification and Negotiation Team members understand and negotiate roles to support collaborative, relationship-focused care using individual strengths and expertise and recognize the person receiving the care as the expert in their experiences.
Team Functioning All team members work interdependently and collaboratively to coordinate efforts, make shared decisions, and achieve shared goals efficiently.
Team Differences/Disagreements Processing Team members address disagreements constructively to maintain team cohesion and respectful relationships.
Collaborative Leadership All team members share leadership and accountability, value each other’s knowledge, skills, expertise, strengths, and perspectives, and support one another in achieving shared goals.
Important considerations underpinning the framework
Inclusion, Access, and Equity Inclusion, Access, and Equity are essential considerations that guide the application of all competencies, ensuring effective collaborative practice within the team that is respectful of the diversity within the team members and the person receiving care. Considerations include differences in culture, ethnicity, race, gender, sexual orientation, ability, socio-economic positions, barriers to accessing care, and the accessibility of services.
Complexity The complexity of each person’s care needs can vary, requiring an individualized, person-centered approach that depends on multiple professions and sectors collaborating with each other.
Care and Service settings The context in care and service settings is an important consideration when collaborating with team members. This includes the person’s circumstances, such as food insecurity, home environment, work conditions, and available supports. This can also include the team’s circumstances, for example, teams that communicate virtually or asynchronously. In these situations, it is essential to consider all available tools, share information amongst all openly, make decisions collaboratively, and respect each professional’s expertise.

License

Navigating The Integrated Stroke Care Journey: Patient and Caregiver Perspectives Copyright © by Dr. Sue Bookey-Bassett; Dr. Sherry Espin; and Sukhanjit Kaur. All Rights Reserved.

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