Pulmonary rehabilitation (PR) is an effective intervention for improving quality of life, decreasing dyspnea, and increasing exercise tolerance in patients with chronic respiratory diseases.1 Pulmonary rehabilitation is defined as “a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies which include, but are not limited to, exercise training, education and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors.”2 Pulmonary rehabilitation is administered by an interdisciplinary team focused on improving functional status, reducing dyspnea, and improving quality of life for patients with chronic respiratory disorders. To deliver a quality program, health care providers of PR services must be competent in understanding and meeting the patient's needs and goals. The purpose of this article is to outline those competencies recommended for personnel providing PR services. This article both reviews and updates the 2007 Clinical Competency Guidelines for Pulmonary Rehabilitation Professionals3 and complements the American Association of Cardiovascular and Pulmonary Rehabilitation's Guidelines for Pulmonary Rehabilitation Programs.4
Competency development for any discipline or program involves describing the knowledge and skills needed to provide the services.5 Professional competence involves clinical skills and reasoning, scientific knowledge, and communication skills to benefit the individuals being served.6 In 2003, the Institute of Medicine issued a report, Health Professions Education: A Bridge to Quality.7 This report emphasized the need to change the education of health care professionals to improve the quality of health care in the United States. Five core competencies were presented in the report for the education of health professionals to meet the dynamic needs of the health care system. These competencies are patient-centered care, interdisciplinary teams, evidence-based practice, quality improvement, and informatics.7 They have been recognized by others8 and are part of the clinical competencies delineated for Core Competencies for Cardiac Rehabilitation/Secondary Prevention Professionals: 2010 Update.9 These core competencies (Table 1) are important for all health care professionals working in PR and serve as the essential elements upon which additional competencies build.
CORE COMPETENCIES FOR PULMONARY REHABILITATION PROFESSIONALS
The PR competencies outlined in 2007 included assessment, intervention and outcome evaluation, and followup. They focused on pathophysiology and comorbidity, professional communication, patient education and training, and exercise and psychosocial needs.3 The clinical competencies outlined within these current guidelines include (1) patient assessment and management; (2) dyspnea assessment and management; (3) oxygen assessment, management, and titration; (4) collaborative self-management; (5) adherence; (6) medication and therapeutics; (7) special consideration for non–chronic obstructive pulmonary disease diagnoses; (8) exercise testing; (9) exercise training; (10) psychosocial management; (11) tobacco cessation; (12) emergency responses for patients and program personnel; and (13) universal standard precautions. The authors recognize that there are areas of overlap in competencies as well as overlap in the knowledge, skills, and abilities listed under various competencies. For example, dyspnea assessment could be included under the patient assessment competency. However, because dyspnea assessment is so crucial to PR practice, it was decided to list it as a separate competency. It is important to acknowledge that not all PR professionals are likely to achieve all the competencies listed herein. Regulatory, educational preparation, and licensure limitations may limit services that any particular PR professional may provide. These competencies, however, provide an overarching and comprehensive knowledge framework of which PR health care professionals should be aware.
Table 2 outlines recommendations for specific core competencies for PR professionals. Compiling core competencies for PR professionals accomplishes four key objectives: (1) key knowledge and skills required by PR professionals are outlined for those working in the field; (2) key knowledge and skills needed for a future career in PR are outlined for academicians preparing future professionals; (3) baseline levels of knowledge components for licensure and certification are provided; and (4) these competencies are incorporated into the American Association of Cardiovascular and Pulmonary Rehabilitation program certification process.
Although no specific competencies are associated with program organization, overall administrative competence is essential to a successful PR program. PR programs share essential features with variability found in available resources, program setting, structure, personnel, and age of the program. The optimal length of PR is unclear, yet longer programs have been associated with greater improvement and maintenance of benefits.2
Historically, PR has been underutilized, with barriers to enrollment including challenges to the patient's schedule, travel, transportation, parking, cost and insurance coverage, lack of endorsement by health care providers, and lack of perceived benefit. Noncompletion of PR may be due to illness, comorbidities, travel and transportation issues, lack of perceived benefits, smoking, depressive symptoms, and lack of support. Contraindications to PR include any condition that could impact safe exercise or provision of PR.10 Pulmonary rehabilitation can be provided in inpatient and outpatient settings, whereas exercise training also can be provided in the individual's home with adequate resources in place.
Health care utilization and costs are reduced after PR, including hospital admissions, hospital days, and emergency room visits.11 PR during or immediately after chronic obstructive pulmonary disease exacerbation reduces hospitalizations and possibly improves survival.12 Challenges to providing PR include regulatory coverage of services, costs, and access. Patients impacted by limited access include those who are homebound or live in rural or remote areas. Technology may offer future options for satellite or alternatives to PR.
We have developed a revised list of core competencies for PR professionals. No individual health care provider is likely to be proficient at everything on this list. In addition, smaller programs may not have the resources for competence in all areas. We propose the components in this document be used as goals for programs to strive for within the context of available resources.
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