THE ROLE OF TRUST IN THE PROCESS OF MEDICAL REHABILITATION – Медицинская антропология и биоэтика

2024 – № 1 (27)

DOI: https://doi.org/10.33876/2224-9680/2024-1-27/05

For citation: Razuvanau A.I., Kozlova S.V., Shnihir A.A. (2024) The Role of Trust in the Process of Medical Rehabilitation: Significance for Patients and Ways to Strengthen It, Medical Anthropology and Bioethics, 1(27).

Alexey Ivanovich Razuvanau –

Candidate of Medical Sciences, Associate Professor;

Academic Secretary:

Government agency

“Republican Scientific and Practical

Center for Medical

Expertise and Rehabilitation”

(Minsk: Belarus)

https://orcid.org/0000-0001-5033-2933

E-mail: doc-rai@yandex.by

Svetlana Vladimirovna Kozlova –

Candidate of Medical Sciences;

Deputy Director for Clinical Work:

Government agency

“Republican Scientific and Practical Center

For Medical Expertise and Rehabilitation”

(Minsk: Belarus)

https://orcid.org/0000-0002-7777-1976

E-mail: zam.clinica@meir.by

Anastasia Anatolyevna Shnihir –

Research Associate:

Government agency

“Republican Scientific and Practical

Center for Medical

Expertise and Rehabilitation”

(Minsk: Belarus)

https://orcid.org/0009-0000-6300-4947

E-mail: violed-li@mail.ru

Keywords: trust, medical rehabilitation, patients, multidisciplinary rehabilitation teams, technological innovations, trust enhancement, patient motivation, individualization of medical rehabilitation, interaction of rehabilitation specialists, ethical aspects, transparency

Abstract. The article examines the role of trust in the process of medical rehabilitation and its importance for successful interaction between patients and specialists in the field of medical rehabilitation. Trust promotes more active participation of patients in medical rehabilitation programs, thereby increasing motivation and improving the final results of medical intervention. The article highlights the risk of “dehumanization” of medical care due to the loss of human interaction. The importance of intra-team trust among multidisciplinary rehabilitation team specialists is also emphasized, which improves coordination and the quality of services provided.

Special attention is paid to the need to build trust within multidisciplinary rehabilitation teams, as well as to the development of tools for assessing the patient’s condition, such as WHODAS 2.0. The authors conclude that the integration of technology and trust plays a key role in ensuring high-quality medical rehabilitation.

Trust is a fundamental aspect in all areas of medical practice. Traditionally, trust in health care has been built on the relationship between patients and physicians, as well as confidence in health care institutions and the health care system as a whole. It is based on patients’ expectations of the quality of care, the professionalism of physicians and the confidentiality of medical information, so it is not surprising that all of these affect adherences to medical recommendations, the success of treatment and, ultimately, the health of society as a whole.

From a bioethical perspective, trust is a strictly ethical issue that arises in various biomedical research endeavors. On the moral side, the problem of trust was first sufficiently highlighted in the Belmont Report «Ethical Principles and Recommendations for the Protection of Human Subjects in Research» in 1979, where basic ethical principles (autonomy, beneficence, justice) were put forward, which became the fundamental regulators of biomedical research [1].

However, with the introduction of electronic medical records, telemedicine, personalized medicine and other electronic innovations, the traditional foundations of trust are being altered. Typically, such innovations raise concerns related to the loss of the human element in patient contact, privacy and security of personal data, and transparency of decision-making.

Therefore, there is a renewed need for a regulation or a single tool to enable the application of electronic innovations in the health care system and to ensure validity, reliability, safety and comprehensibility for all immediate and distant end results. Integration of various data sources (results of laboratory and instrumental methods of research, various visual information from patients’ medical records, information about appointments of specialized doctors, etc.) into one digital system helps to ensure a comprehensive approach to the management of the patient’s health. An important link for building trust is the education and training of health care professionals in working with new technologies, which will increase their competence and confidence in the use of innovations. At the same time, it is important to maintain a balance between technological innovation and human interaction, as face-to-face communication and individualized care continue to play a key role in patient care.

Consequently, the elements of eHealth, and the innovation that results from them, represent a significant potential for improving the quality of health services. Creating a system that is both innovative and trustworthy requires a collaborative effort between academia, technology developers, health professionals and patients. It is important that every aspect of technology adoption is carefully considered in terms of ethical and social implications to ensure that trust is maintained at all levels [8, 9, 15, 17, 18, 21, 29].

Trust also plays an important role in the process of medical rehabilitation; it contributes to the successful recovery of patients, helps to create a favorable atmosphere for interaction, where patients feel support and confidence in their abilities. A high level of trust contributes to more active participation of patients in rehabilitation programs, improving their motivation and, therefore, achieving better final results.

Today, modern medical rehabilitation methods include a wide range of technological innovations aimed at improving the functional recovery of patients after injuries, surgeries or chronic diseases. One of the key trends is the use of robotic systems and virtual reality to help restore motor functions. According to the StartUs40 platform, in 2023, the top ten global trends in the development of new technologies influencing the efficiency and accessibility of medical rehabilitation services are: immersive technologies, telerehabilitation, wearable devices for medical rehabilitation, rehabilitation robotics, personalized diagnostics, artificial intelligence, offloading technologies, big data and analytics.

The use of robotic systems and virtual reality in medical rehabilitation ultimately allows for dosed and standardized interventions, adapting the load and complexity of medical rehabilitation programs depending on the progress of the patient. For example, virtual reality (VR), which is used to create immersive environments, encourages patients to perform rehabilitation exercises. VR platforms can simulate real-life scenarios or gaming tasks, making the medical rehabilitation process more interesting and motivating. Such technologies are particularly effective in neurorehabilitation, where it is important to engage patients in active activities that help restore neuroplasticity.

However, the use of robotic systems and virtual reality, on the one hand, can significantly increase the effectiveness of rehabilitation interventions, on the other hand, may raise concerns about the «depersonalization» of medical care and the loss of an important element of human interaction between the patient and the specialists of the multidisciplinary rehabilitation team (MDRB), which, in turn, poses a threat to «dehumanize» the process of medical rehabilitation. In addition, one of its major challenges is the lack of ability of innovative programs to adapt to the individual needs of each patient, including the fine-tuning and personalization of exercises for the purposes of effective medical rehabilitation.

The World Health Organization (WHO) also emphasizes the importance of trust in health care systems for their effective functioning. Despite the complexity and versatility of the concept of trust, it is necessary to understand that it is the foundation of relationships in the health care ecosystem, including between health care providers and patients, within clinical teams [31].

In relation to trust in health systems, the WHO identifies a number of problematic issues:

Public misinformation – the dissemination of distorted or knowingly false information can undermine trust in public health authorities, leading, for example, to reduced utilization of medical rehabilitation services by patients.
Marginalization and discrimination – marginalized communities can lose trust in the health system due to unequal access to health care, poor quality of health care delivery, including medical rehabilitation, and worse health outcomes.
Lack of transparency. Lack of transparency about health care costs, open admission of medical errors, or concealment of conflicts of interest can undermine trust in the broader health care system. Patients and the public perceive a lack of accountability, ethical behavior in the health care system, and decreased trust in maintaining personal privacy due to little or no technological reliability, fairness, and ethical use.

Transparency is particularly appropriate in relation to medical errors, whether they actually occur or are considered routine. They can lead to patient harm or even death, and can undermine trust in medical, rehabilitation, pharmaceutical, health care providers, health care facilities and the health care system as a whole [30].

It should also be noted that the trust of health workers themselves in the health system is also of great importance, as its loss contributes to labor shortages and reluctance to make the necessary changes [31].

The thesis of trust is also confirmed by the studies of foreign colleagues [6]. Thus, the widely discussed generative artificial intelligence (AI) technologies in clinical practice are ready to use and are used by 20% of specialists. Reluctance to trust such technologies is due to the fact that there is no clear confidence in their effectiveness due to a number of factors:

Concerns for clinicians are related to the ability of AI to generate false information, leading to an erosion of trust, especially in clinical practice where the accuracy of results is critical.
There are concerns about the use of patient data by AI technologies, whether this is consistent with privacy and ethical principles. The opacity of AI companies’ use of data raises questions about respect for patients’ rights.
The emergence of additional cause for concern among physician specialists due to the risk of AI technologies’ ability to exacerbate existing health care disparities (gender, race, and other characteristics).
The existing lack of formal guidelines and policies governing the use of AI technologies in clinical practice [6].

Despite the extensive research in the area of patients’ trust in health care providers, measures taken to improve this qualitative characteristic have shown little positive effect on health system outcomes. Thus, the WHO notes that in order to address the issue of trust between doctor and patient and to understand its level between specialist physicians and nursing staff, there is a need for tools to measure it, especially to assess trust in physicians and MDRBs, including within them [31].

Trust among MDRO members is key to ensuring successful and quality patient care. When professionals from different areas of medicine, such as medical specialists, nurses, nurse practitioners, peer educators and psychologists, work together, trust becomes the basis for effective collaboration, coordination, decision-making and job satisfaction. It is the built intra-team trust that promotes open and honest exchange of information among team members, which reduces the risk of misunderstanding and errors in planning and implementing rehabilitation programs [25]. Team members who trust each other are more likely to make collective decisions, taking into account the professional competence of each participant. This increases the quality of decisions and the effectiveness of interventions [5]. Under conditions of trust, professionals feel valued members of the team, which increases their job satisfaction and reduces stress levels, and therefore has a positive impact on patients [26].

Consequently, trust among MDRB members is an important factor in ensuring successful medical rehabilitation and a high level of quality.

The organization of rehabilitation teams plays a key role in the recovery of patients requiring medical rehabilitation interventions. There are several approaches to organizing the work of such teams: multidisciplinary, interdisciplinary and transdisciplinary [4, 13, 14, 19, 22, 24].

Each of these approaches differs in the level of specialist interaction, degree of coordination, and decision-making methods.

Multidisciplinary teams are made up of specialists from different disciplines (medical and non-medical). In this approach, each specialist works in parallel, with responsibility for his or her specific area of medical rehabilitation. Specialists conduct their own assessments and develop separate intervention plans, which are then applied to the patient. Interaction between team members is minimal, and each specialist focuses solely on his or her area of responsibility. The main advantage of the multidisciplinary approach is the autonomy of each team member. Specialists can focus on their narrow area of expertise while providing high quality services in their field. On the other hand, a lack of coordination among team members can lead to a lack of integrity in medical rehabilitation, which can worsen patient outcomes. An example of this approach might be when a physical therapist and a psychologist work with a patient but do not discuss a joint plan of action [20].

The interdisciplinary approach involves closer collaboration between professionals. In this model, team members coordinate their activities, discuss the results of the patient assessment and develop a common, coordinated program of medical rehabilitation. This avoids duplication of effort and improves communication within the team. In this regard, each specialist not only fulfills his or her role, but also actively interacts with others, taking into account their opinions and recommendations, which contributes to a more holistic approach to the patient’s medical rehabilitation. The interdisciplinary approach is particularly effective in rehabilitation teams where constant coordination between different specialists is necessary to achieve the best results. For example, medical rehabilitation after stroke may involve the work of a physiotherapist, a neurologist and a psychologist who work together to develop a program of rehabilitation activities and regularly evaluate its results [19].

The transdisciplinary approach implies an even deeper integration of specialists. Here, team members not only coordinate their actions, but can also perform functions not directly related to their specialty. This allows for maximum flexibility in the approach to the patient’s medical rehabilitation. Specialist roles can overlap, which contributes to a more versatile team. Importantly, team members learn from each other, developing skills in related disciplines. This ensures that each specialist is able to perform tasks that traditionally belong to other team members. This approach requires a high level of trust and open interaction between specialists. An example would be when a physical therapist is not only responsible for physical recovery, but also coordinates psychological support for the patient, drawing on the knowledge gained from the team psychologist. This allows for a more adaptive and holistic system of medical care [22].

Consequently, the main difference between the approaches is the level of coordination and interaction. Multidisciplinary teams work in parallel with minimal interaction. Interdisciplinary teams actively collaborate, joining forces to create a common rehabilitation plan. Transdisciplinary teams are as integrated as possible, facilitating a more flexible and personalized approach to medical rehabilitation.

Thus, the choice of approach depends on the specifics of the rehabilitation process, the team’s objectives and the patient’s condition. In settings requiring high coordination and integrity of medical rehabilitation, interdisciplinary and multidisciplinary approaches may be preferred.

There are several tools available to assess the confidence and performance of multidisciplinary rehabilitation teams/teams. The following questionnaires are examples:

TEAM (Team Evaluation and Assessment Measure) – this tool was developed for self-assessment of multidisciplinary teams working in oncology. It covers aspects such as leadership, team culture, patient-centeredness and clinical decision-making processes. Studies have shown that the tool has good psychometric properties and helps to identify areas for improvement in team performance [28].
TFAT (Team Functioning Assessment Tool) – this tool assesses clinical planning, task performance and team relationships. TFAT has been tested in a medical ward setting and has shown reliable results [27].
CPSET (Care Process Self-Evaluation Tool) – this tool is designed to assess the organization of care processes in multidisciplinary teams. It includes 29 items that cover aspects such as care coordination, interaction with primary care and communication with patients and their families. The CPSET has been evaluated as a reliable and valid instrument [23].
Multidimensional Trust Measure – this tool was developed to measure trust within teams, including aspects such as trust propensity, perceived trustworthiness and behavioral aspects of cooperation. It has been tested on various samples and has shown good psychometric properties [11].

In our view, building trust in medical rehabilitation is closely linked to the availability of clear and consistent methods of patient assessment. The introduction of a single tool for assessing patient functioning that can be used by the entire multidisciplinary team is an important step towards increasing trust on the part of both patients and health care providers.

A single assessment tool allows all members of a multidisciplinary team, including medical specialists, psychologists and nurses, to work with a consistent set of patient data. This provides not only a holistic understanding of the patient’s condition, but also allows the team to act in a coordinated manner, avoiding miscommunication and duplication of effort.

The use of a single assessment tool promotes greater transparency in the medical rehabilitation process. Patients receive clear and understandable information about their condition, progress and rehabilitation goals. This, in turn, builds their trust in the medical team, as patients see that all professionals are working in sync and have the same level of knowledge about their condition. When patients realize that their condition is being assessed using a standardized, evidence-based tool, it increases their confidence in their treatment pathway.

A single assessment tool helps create a more coordinated and focused rehabilitation program. Team members can easily share information and discuss the patient’s condition based on a single assessment. This eliminates potential differences in approach to developing rehabilitation interventions and facilitates faster and more cohesive decision-making. For example, if a tool identifies a need for increased focus on a particular function, this can be instantly incorporated into a medical rehabilitation program agreed upon by all team members.

The WHODAS 2.0 questionnaire (World Health Organization Disability Assessment Schedule 2.0, WHODAS 2.0) recommended by WHO can be such a tool. The reason for choosing the WHODAS 2.0 questionnaire as a reference is its conceptual basis – the International Classification of Functioning, Disability and Health (ICF). In addition, WHODAS2.0 is etiologically neutral [30], which allows measuring the effects of the impact of any disease on a person’s functioning. WHODAS 2.0 covers all domains and areas of the ICF and is applicable to the assessment of limitations of functioning in the effects of multiple diseases: mental and somatic [30].

The WHODAS 2.0 questionnaire is a set of items/questions grouped in various ways into the following independent domains: ‘understanding and communication’, ‘mobility’, ‘self-care’, ‘socializing with people’, ‘life activities’, ‘social participation’. Each item/question on the questionnaire is answered with one response from the following five statements: «no», «little difficulty», «moderate difficulty», «difficult», «very difficult or impossible». At the moment, the staff of the state institution «National Science and Practice Centre of Medical Assessment and Rehabilitation» (Minsk, Republic of Belarus) is adapting it [3].

Thus, in the process of providing the necessary medical services in the field of medical rehabilitation, work within the MDRB takes a special place due to the fact that medical rehabilitation emphasizes the maximum possible physical, emotional and psychosocial well-being and independence of the patient. At the same time, work in MDRB should not consist of collecting the conclusions (opinions) of several specialists on a particular case, but should involve an interdisciplinary approach, which implies the search for the optimal rehabilitation route (drawing up an individual program of medical rehabilitation of the patient with the definition of tasks at each stage of medical rehabilitation) [7, 2].

Consequently, it is important to consider several key aspects in order to build trust in the medical rehabilitation process:

Patients should receive complete and accurate information about their condition, methods of medical rehabilitation and possible risks. This will enable them to make informed decisions and build confidence in MDRB specialists and the technologies used.
In a digital medical rehabilitation environment, special attention should be paid to the protection of patients’ personal data. It includes the use of strong encryption systems and strict security protocols to prevent information leaks [12].
The introduction of new technologies requires appropriate training and professional development for MDROs. This includes training in the use of new devices and programs, as well as understanding the ethical aspects of their use [16].
An important aspect is to take into account the individual characteristics of each patient, including their cultural, religious, social and personal preferences. This contributes to a more personalized approach to medical rehabilitation and increases trust [10].

In addition, it should be noted that such criteria as patients’ own awareness and personal experience also influence the formation of patients’ level of trust in medical technologies and innovations. They determine the ability of people to understand and assess the risks and benefits associated with the use of new technologies in healthcare.

Awareness – access to up-to-date information about new technologies and their impact on health – can increase patients’ trust in physicians. Transparent and open communication about the capabilities and limitations of technologies, as well as safety and efficacy standards, builds trust.

Personal positive experiences can greatly increase confidence in medical technology, while negative experiences can create doubt and distrust.

Thus, trust plays a key role in the success of medical rehabilitation, as it affects the level of interaction between patients and MDRB specialists, motivation and adherence to rehabilitation measures. However, to ensure an effective process of patient rehabilitation, in our view, it is necessary not only to strengthen their trust in medical professionals, but also to create conditions for intra-team trust (interdisciplinarity) among MDRB specialists. In order to achieve the latter, it is important to develop a new unified and understandable for each of the MDRO participants tool for determining the main tasks of the rehabilitation process. In this case, the new tool will form the basis of expert rehabilitation diagnostics, the results of which will be used to draw up an individual medical rehabilitation program for the patient. It can be assumed that its use will improve the coordination of MDRO specialists’ efforts and contribute to the improvement of the quality of medical services.

List of abbreviations

WHO World Health Organisation

AI Artificial Intelligence

MDRB Multidisciplinary rehabilitation team

ICF International Classification of Functioning, Disability and Health

CPSET Care Process Self-Evaluation Tool

TEAM Team Evaluation and Assessment Measure

TFAT Team Functioning Assessment Tool

WHODAS 2.0 World Health Organization Disability Assessment Schedule 2.0

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