A Learning Culture of Osmosis: The TDT model in Neurobehavioural Rehabilitation

A transdisciplinary team (TDT) model is one of the cornerstones of Neurobehavioural Rehabilitation. It’s a distinct form of collaborative working where traditional disciplinary boundaries are more integrated and roles are shared to maximise interaction, communication and programme delivery.

A TDT approach makes rehabilitation a 24-hour process, increases opportunities to practice and learn skills, and requires all members of the team to be familiar with every patient’s individualised programme. It’s a unique, holistic approach that often distinguishes itself from other rehabilitation services.



In this EveryExpert article we speak with Andy Birkett, Hospital Director at the Avalon Centre, a neurological centre for men and women who have an acquired brain injury. The centre has been designed specifically to support people who, because of their injury, have challenging and complex needs and require a Neurobehavioural Rehabilitation programme. Originally trained as a nurse, Andy has more than 25 years of specialist neurobehavioral rehab experience in a variety of different leadership roles within brain injury services, as well as within community-based homes.

Andy is passionate about the benefits of a Transdisciplinary Team (TDT) model and an advocate for how shared understanding in rehabilitation can help improve patient outcomes. In this article we discuss how Andy and the Avalon team are working together to create a holistic rehabilitation culture with an ongoing osmosis of knowledge and practice occurring throughout all patient’s daily routines.


Hi Andy, thank you for speaking with me today. Before we get into the specifics of how the Avalon Centre provide Neurobehavioural Rehabilitation, can I begin a step before that, for the benefit of the readers, and ask what is a Transdisciplinary Team (TDT) approach in your understanding?


“Of course. For me, a TDT approach is the facilitation of behavioural change (rehabilitation) within structure rich services (routine, environment and implementation), by a team of nurses, therapists, doctors and psychologists, who create a supportive environment which motivates, shapes and optimises change.

“As a model of working, the historic traditional boundaries of each discipline become integrated. Responsibilities are shared and patients benefit because there are less gaps in rehab – each and every interaction is an opportunity for rehab.

“This is a real strength of the model. When you have different expertise and experience pooled together, it really helps to improve assessments and then the planning and delivery of interventions.”



So how the team is organised is an important factor?

“Yes, the way the clinical team is organised is especially important in ensuring the degree of consistency required to facilitate new learning in people with cognitive impairment, in optimising opportunities to deliver rehabilitation, and in creating and maintaining a positive social environment.

“The aim of rehabilitation is not simply to achieve socially functional behaviours but to help these behaviours become established as social habit patterns. This means their likelihood is increased and generalised to other environments and improve potential for social independence. In this regard, delivery of the service model by a TDT is essential.”


That sounds very impactful, are there any other benefits of a TDT approach?


“TDT provides more consistency across the team because each individual is working together on the same care plan, towards the same, agreed outcome. Be they a physio, psychologist or care worker, they all participate in an agreed method to achieve personalised outcomes for everyone we support.

“Team members come together right from the beginning of the care plan to share ideas from their different perspectives about what would benefit the patient, they collaborate and work towards shared goals.

“In this way the rehabilitation is holistic and addresses all the patient’s needs. In fact, patients’ needs define everything, including what the role each person has. The different professionals involved in the individual’s care need to respond to what the individual presents rather than what their discipline has traditionally told them to do.

“A TDT model of working also enables feedback between team members, because of its collaborative nature and allows us to continually monitor progress. This means we make adjustments whenever and wherever necessary, it’s much more flexible, because every team member is working together.”



So does this result in a more intensive rehabilitation programme for the patient?

“Yes, absolutely. Interventions are provided whenever the patient needs them, not just when a set schedule has said they will happen. And because every team member is trained on these interventions, we’ll work on them throughout the daily routine, without interruption.

“They are continually applied, and this means that any effort and achievements by the patient are reinforced through interaction with every member of the team. This is a crucial element to understand – reinforcement of behaviour enables a modification or change in behaviour.

“So what that means is, if we can modify unwanted behaviour, such as physical and/or verbal aggression or antisocial behaviour, through reinforcing desired behaviour, such as getting washed and dressed or attending therapy sessions, then we can make progress with rehabilitation.

“In this way, the net effect of a TDT delivering interventions, based on new learning within a highly structured environment, will be the creation of a ‘relentlessly positive’ team ethos. And then in turn, development and maintenance of an enriched social climate that promotes excellent therapeutic relationships and outstanding clinical outcomes.

“But we can only do that if all team members are consistent in their approach. For example, a morning routine may have a set number of prompts to complete and would normally take 1 hr. But on some days the patient may not engage as much with the routine, but as a care team we must remain consistent in our approach. Even if the routine lasts for hours – and sometimes they can (I’ve been in morning routines that have lasted five hours), as a team we cannot skip anything or reinforce unwanted behaviours, because we can then hinder the progression of the patient.”



That must be a challenge for the team member themselves?

“Yes, it is, but this is where training, understanding and empowerment play an important role. The whole team are empowered to understand the importance of their roles, and to see themselves as an agent for behaviour change. Each person in the team is integral to the success of the rehab.

“We make sure that everyone knows why they are doing an intervention and how it will impact the patient if they don’t.

“It is essential the team buy into the targets and interventions, historically there have been occasions where a staff member found the interventions too difficult and did things differently, whilst this made their work life easier it effectively dismantled the programme everyone else was trying to deliver and halted rehabilitation progress.”


A TDT model must produce quite a unique working culture then?

“Yes, it does. For me it’s a culture where learning takes place through osmosis, so to speak. Learning, sharing ideas, making adjustments and refining our approach is happening all the time.

“And it takes a certain type of mindset to fit into this type of working culture – it’s not for everyone. Sometimes individuals prefer to have more defined boundaries, to work less collaboratively. But at the Avalon Centre we are building something that is the opposite of that, its team working in its fullest form.

“Because we have more communication, there’s more cohesion with the team. We’re all committed to working together and learning from each other. It brings real satisfaction and a sense of collective identity.”



Does that mean that when you recruit new colleagues you’re looking for certain type of person to work at the centre?

“Absolutely – it isn’t always about how experienced the person is, or their skill set (although of course that is important). But with a TDT model, it is just as much about the person, their mindset and how they can work within the team.

“The Avalon Centre is a Neurobehavioural centre, we work with individuals who are not able to attend more mainstream rehabilitation placements. With the individuals we support we need to separate the person from their behaviour and understand how their brain injury has created challenging and complex needs which are preventing access to normal society and life.

“Due to whatever has happened in their lives’ after their brain injury – perhaps relationship breakdowns, or they were unable to function within society – behaviour is one of the few remaining things that they have control over. Our team need to recognise that and work with that behaviour to adapt it.”



I imagine the individual’s family also play an important role in the rehabilitation process?

“They’re integral. But it is often very difficult for them, because the person they knew is not there anymore. The brain injury means that the individual we are supporting is often very different to the one they knew and loved. The family are still in the process of adjusting to this, and often they haven’t received the support they need to be able to do this. It’s very hard for them.

“If the family can be partners in the rehab programme and help with some of the delivery of therapies or interventions, then it can be really impactful. For example, we have a father who is helping his son with the walking element of his rehab. The son engages more with his father and rehab is progressing well. Trying to generalise the structure from the unit into home and external settings aids that consistency.”

“Whilst a Neurobehavioural programme can be a lengthy process because it takes time to modify behaviours and establish new patterns, we are very focussed on supporting each person to achieve their own rehabilitation goals so they can move past the barriers that are preventing them from getting on with their life. This will still often be with support and may look very different to their life prior to the brain injury but should be back at home or in a less restrictive community setting.”