Introduction

In 2021, the World Health Organization launched the Rehabilitation Competency Framework (RCF), which describes the competencies and activities of the rehabilitation workforce [1]. The framework is relevant to all occupations that deliver care that aims to optimise functioning and reduce disability. It crosscuts specialisations and settings, and is, therefore, capable of being adapted and adopted for application in any specific context [2]. In its original form, the RCF provides a unique opportunity to conduct a competency analysis of the rehabilitation workforce. This has not previously been possible due to the absence of: (1) a shared description of proficiency levels that spans the spectrum of qualifications and expertise encompassed within the rehabilitation workforce; and (2) a comprehensive list of tasks that indicate the scope of rehabilitation care delivered by the rehabilitation workforce collectively. The RCF addresses both these barriers, opening the door to a new level of workforce evaluation extending beyond that of traditional health labour market analysis (HLMA).

Methods

Study design

This study employed participant observation methodology, whereby two researchers (authors JM and WK) were immersed in the pilot, enabling them to interact with the GRoWE resources and experience each step of implementation. The authors further observed the time taken to complete the different competency analysis exercises, the challenges experienced by the stakeholders completing the exercises, how the findings were reported and how they were interpreted and applied in rehabilitation workforce planning.

Key informant interviews were also conducted with experts engaged in the evaluation, including those working in policy, education, professional associations and clinical practice. Lines of enquiry explored stakeholders’ experiences in identifying and reporting data, their perception of the findings and their added value, as well as their recommendations for future evaluations.

Study population

This study draws on the insights of the following stakeholders:

  • The WHO personnel overseeing the development and piloting of GRoWE (JM)

  • The project officer responsible for implementing GRoWE in Poland (WK)

  • Experts engaged in the evaluation (n = 5). The demographic profile of the experts is presented in Table 2.

Table 2 Demographics of key informants (experts) and their contribution
Full size table

Recruitment

The GRoWE project officer (WK) disseminated an invitation to participate in feedback interviews via email to the experts who had engaged in the evaluation. The email included a participant information sheet (translated into Polish) and a link to a survey which showed the times available for interviews, and asked if interpretation would be needed. Participants interested in being interviewed were directed to complete the form and contact the WHO focal point (JM), who provided a consent form (also translated into Polish) and confirmed the time of the interview.

The relatively small sample of key informants partly reflects the challenges associated with recruiting individuals who are typically time-poor as well as the size (n = 42) of the pool of potential interviewees (i.e., experts who had participated in the evaluation). Nonetheless, the sample represented a wide range of perspectives, including policy makers, researchers, educators, practitioners, and leaders of professional associations. Finally, the themes emerging from analysis of the data achieved saturation, suggesting that additional interviews would not have generated new insights.

Data collection

Key informant interviews were conducted by the WHO focal point and were recorded and transcribed using Microsoft Teams. Interpretation was offered to all key informants, but was only partially used by two, predominantly when technical language was being used. Transcripts were manually cleaned for analysis. Data from the participant observation were gathered through a systematic debriefing between the WHO focal point (JM) and GRoWE project officer (WK). The debrief involved detailed, goal-focused discussion, framed around the topics of engagement, feasibility, perception, added value and additional lessons learned. The data from the debrief were compared with the findings from the key informant interviews and the results of the competency analysis. These triangulated data were discussed by all authors of this paper.

Data analysis

Thematic analysis of the interview transcripts was performed using NVIVO software. Results of the thematic analysis were reviewed and agreed by all authors and compared with observational findings.

Ethical approval

Ethical approval for this study was obtained from the Human Research Ethics Committee of The University of Sydney, Australia (project number 2021/824).

Results

Analysis of the data from the key informant interviews and project officer debrief revealed several themes related to the perceived value of the competency analysis, as well as of the evaluation more broadly. Themes also emerged around challenges experienced with data collection and quality, and several experts offered suggestions for strengthening future implementation of the evaluation. The main themes are elaborated below. Note that key informants and the project officer are referred to as “experts”.

Working with the concept of a rehabilitation workforce

GRoWE was designed as a resource for the rehabilitation workforce collectively, rather than for any specific occupation. This was reflected in the competency analysis in particular, which presented rehabilitation assessments and interventions targeting a range of areas of functioning (e.g., mobility, communication, respiration, mental health.). Experts reported that participating in an evaluation that adopted the concept of a “rehabilitation workforce” challenged the identity of some occupations and expanded stakeholders’ understanding of what rehabilitation is and what its workforce comprises. For example, many speech and language therapists, who in Poland work primarily in the education sector, had not considered themselves as health workers or as rehabilitation workers. Conversely, psychologists in Poland had been working hard to promote themselves as rehabilitation professionals, but had encountered challenges due to the narrow perception of rehabilitation in the country. Experts noted that rehabilitation is largely synonymous with physiotherapy and rehabilitation medicine in Poland, and that other occupations, especially those which do not primarily address ‘physical’ impairment, are overlooked. The GRoWE project officer noted, “There are two queens or kings—doctors and physiotherapists—and the rest are underestimated”. GRoWE challenged this perception, placing equal importance on the competencies and tasks of each occupation included in the evaluation.

Identifying and managing scopes of practice

The competency analysis was reported by experts to be valuable in addressing the issue of informal task sharing. Task sharing was noted to be widespread among the rehabilitation workforce in Poland, especially in relation to physiotherapists absorbing tasks from the scopes of practice of occupational therapy and speech and language therapy. Task sharing was considered to be necessary in Poland given the underdevelopment of many of the rehabilitation occupations but was not always well-supported with education and training. Furthermore, it was suggested, physiotherapists tended to assume that they were responsible for all or most rehabilitation tasks—a belief that likely stems from the absence of other occupations in many settings. As one expert reported, “we need to make the space for [other occupations], because sometimes physiotherapists here in Poland are thinking that they are all in one, but we are not” (KI5).

The competency analysis was considered by experts to be useful in showing which occupations were working at what level and what tasks were being performed by whom. This was seen as central to ensuring “proper use of available workforce” (KI2). Despite some limitations in the competency analysis (see data collection and quality below), the results were seen by experts as an important starting point for discussion and as the basis for the development of more comprehensive competency analysis tools.

Multidisciplinary collaboration

A perceived benefit of GRoWE in general and the competency analysis exercises in particular was its ability to foster collaboration between the different rehabilitation occupations. Experts noted that, although some occupations were accustomed to working together in the clinical setting, this rarely translated into cooperation in workforce evaluation and planning. Completion of the exercises necessitated teamwork, while the workshops brought all occupations together around a virtual table, with a common aim. Experts noted that this had previously been lacking. One expert stated, “I was missing this openness and the willingness to cooperate between the different sections of the rehabilitation system. Therefore, it was perfect for me” (KI5).

Data collection and quality

All experts noted challenges with data collection and quality. These related to all aspects of the evaluation, but reliability was specifically flagged as a concern for the competency analysis. This concern was linked to the subjective nature of the competency analysis exercises, which relied on a small sample of workers reporting on behalf of their wider occupation. The project officer reported that some stakeholders felt uncomfortable with the responsibility of representing their workforce. For example, when completing the competency analysis exercises, participants reported tension between responding based on what is expected of the occupation and the actual performance of workers. While the instruction for the exercises was to report actual performance, it was not always possible for the sample of workers completing the exercise to gauge this. Concerns about reliability were greater for unregulated occupations, such as occupational therapy, for which there is considerable variability in levels of proficiency and scopes of practice. Given these concerns, experts felt that the results of the competency analysis should be interpreted as preliminary and used to facilitate further investigation. It was also suggested that a survey instrument and/or focus groups could be used in addition to the exercises to obtain a wider range of perspectives and opinions, thereby strengthening the reliability of the data.

As the GRoWE pilot in Poland took place in the context of the COVID-19 pandemic, stakeholders had to meet virtually, and data collection occurred via emails, phone calls and online meetings and workshops. This format was considered by the experts to have several benefits, including greater flexibility and the ability to engage stakeholders from different geographic regions of the country. The GRoWE project officer noted however, that face-to-face discussion among stakeholders, even in a single workshop, had the potential to strengthen stakeholder engagement with the evaluation. Meeting in person was thought to enable better communication and connection among stakeholders (especially those who had not known each other prior to the evaluation) and between stakeholders and the project officer, to whom data were reported. Experts tended to agree that a hybrid approach would be optimal, with online communication complemented by at least one in-person workshop.

Discussion

Traditionally, health workforce evaluation has focused on labour market analysis. The present study is the first to examine how competency analysis can complement labour market analysis in the context of national workforce planning for rehabilitation. To date, the application of competency analysis has been limited to the evaluation of specific workforce contexts, such as emergency preparedness or optimising the nursing and midwifery workforce in low-resource countries. Specifically, this study aimed to assess the feasibility, perceived added value of integrating competency analysis into national rehabilitation workforce evaluation, and its ability to shape rehabilitation workforce planning. These questions were examined in the context of the pilot of GRoWE in Poland, during which participant observation was conducted by the GRoWE project officer and the WHO focal point, and key informant interviews were conducted with experts engaged in the evaluation. Analysis of the triangulated data indicated that such integration was feasible and that it added considerable value to the rehabilitation workforce evaluation.

Feasibility

The expansion of platforms for online working and the increased familiarity with remote working associated with the COVID-19 pandemic enabled GRoWE to be implemented virtually. This greatly enhanced its feasibility, allowing stakeholders from different parts of the country to engage and minimising the disruption to their regular work. However, a hybrid approach, whereby at least one workshop is held in person, is likely to be optimal as it will provide an opportunity to complete more challenging analysis exercises in the presence of the project officer. In-person workshops will further strengthen GRoWE’s role in fostering relationships among stakeholders, especially those from different occupations, and build greater rapport between the stakeholders and project officer, which may help to sustain their participation throughout the evaluation. Such a hybrid approach was adopted with great success in other pilots of GRoWE that were conducted in Rwanda and Nepal after the pilot in Poland had commenced. These additional pilots also demonstrated that the ideal balance between in-person and virtual working is context-dependent and is influenced by what is considered culturally appropriate and the availability and uptake of the required technology.

The method of using a small representative sample of workers from each occupation was initially adopted by GRoWE to address the challenges associated with coordinating large groups of people to complete shared exercises and achieve consensus. Although this approach enhanced the feasibility of the competency analysis, it reduced the reliability of the data for occupations with a large workforce. This may not be of concern when GRoWE is implemented in countries with a much smaller supply of rehabilitation workers, where a sample of 5 workers may represent 25% or more of the occupation. When this is not the case, the use of additional data collection instruments to obtain input from a wider range of perspectives would be valuable. A survey instrument could be developed to complement the existing analysis exercises and serve to verify their findings.

In summary, the use of virtual meeting platforms and the ability to use samples of workers to represent each occupation made the integration of competency analysis in Poland’s evaluation of the rehabilitation workforce feasible and suggests that it could be used in other countries and possibly with other occupational groups. However, the resource requirements and logistical burden of conducting the competency analysis exercises need to be acknowledged, and necessitate a commitment to using the findings to further develop the workforce.

Perceived added value

In this case study, the competency analysis complemented traditional labour market data in several ways. First, from a practical perspective, the competency analysis data provided information on task allocation and worker proficiency that can guide action in education and inform decisions and practices around task sharing, which are critical in a country without an adequate supply of workers. Second, through participating in the competency analysis exercises, stakeholders became aware of the concept of a rehabilitation workforce and the broader scope of rehabilitation interventions. As such, the competency analysis exercises served as mechanisms for education and advocacy. This was particularly significant for occupations, such as occupational therapy, speech and language therapy and clinical psychology, who are less likely than physiotherapists or physical and rehabilitation medicine doctors to be seen or valued as rehabilitation workers, despite their unique and critical contributions. Third, the competency analysis identified the kinds of data that are important to collect and report, or routinely explore. This may help to improve future data collection practices beyond the evaluation itself.

Impact on rehabilitation workforce planning

It remains to be seen what impact the competency analysis data will have on rehabilitation workforce planning in the months and years ahead. However, experts believed that both the process and results of the analysis will strengthen planning and development by: fostering cooperation between different occupations, which has heretofore rarely occurred at a policy and planning level; identifying the types of data that are important to collect and report; and providing information about the allocation of tasks and proficiency of workers. The latter may also help guide the design and delivery of rehabilitation workforce education in the country by highlighting possible areas of underperformance and areas for interdisciplinary training to facilitate task sharing.

Limitations

This study captured the findings from only one pilot of GRoWE, which was conducted in a high-income country. However, the feasibility of the competency analysis, the extent to which it is valued and its impact on planning may differ from country to country. The results of this pilot should, therefore, be interpreted with caution, and lessons should continue to be drawn from the further implementation of GRoWE in future.

Conclusion

Competency analysis appears to be a valuable addition to labour market analysis for evaluating the rehabilitation workforce. The approach is of potential interest to other health-related occupational groups, such as the vision or hearing workforce, which comprise a number of occupations that make unique but interrelated contributions to patient care. Competency analysis in the context of national workforce evaluation is a novel practice and, while it is an exciting innovation, its application should be approached with an openness to learning and adaptation.