Maintaining Professional Standards in Disasters and Conflicts

Original Editors - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Jess Bell, Lilian Ashraf, Aminat Abolade and Kim Jackson      

Introduction[edit | edit source]

Rehabilitation has been increasingly recognised as a necessary aspect of the medical response and patient-centered care in emergency settings, as demonstrated initially by its inclusion in the Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters,[1] and subsequently in the Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams,[2] which clearly sets out the minimum standards and recommendations for optimal care.

Maintaining professional standards in disasters and conflicts is of vital importance for rehabilitation professionals. A principled rehabilitation response is comprised of both clinical and operational interventions that are guided by and adhere to core standards and a patient-centred focus on quality, safety and protection. At the same time, the response must recognise and adhere to local regulations and standards of care. Rehabilitation professionals also need to exercise special precautions to ensure they are ethical in their conduct and that their actions respect core humanitarian principles, and meet core clinical standards of care.[3]

Humanitarian Principles[edit | edit source]

The core humanitarian principles of humanity, impartiality, independence and neutrality, originate from the work of the International Committee of Red Cross and the National Red Cross/Red Crescent Societies. They are based on International Humanitarian Law and provide the foundation for integrated and widely accepted codes of conduct, commitments and core standards that underpin the ‘humanitarian’ response.[2] These humanitarian principles have been formally enshrined in two General Assembly resolutions. The first three principles, humanity, neutrality and impartiality, known as the humanitarian response solution, were endorsed in United Nations General Assembly Resolution 46/182 of 1991, while the fourth principle of independence was endorsed in 2004 under Resolution 58/114.

These humanitarian principles provide the fundamental foundations for humanitarian action which rehabilitation professionals working as humanitarian responders should adhere to at all times. These principles are central to establishing and maintaining access to affected people, whether in a disaster or a complex emergency, such as armed conflict. They should guide you in all your decisions.[4]

Table 1. Core Humanitarian Principles[4]
Humanity Neutrality Impartiality Independence
Human suffering must be addressed wherever it is found. The purpose of humanitarian action is to protect life and health and ensure respect for human beings. Humanitarian actors must not take sides in hostilities or engage in controversies of a political, racial, religious or ideological nature. Humanitarian action must be carried out on the basis of need alone, giving priority to the most urgent cases of distress and making no adverse distinction on the basis of nationality, race, gender, religious belief, class or political opinion. Humanitarian action must be autonomous from the political, economic, military or other objectives that any actor may hold with regard to areas where humanitarian action is being implemented.
Particular attention should be paid to the most vulnerable in the population, such as children, women, older people and people with a disability. Rehabilitation must be provided without discrimination and guided solely based on needs, and priority must be given to those with the most urgent need.

Regulation and Professional Standards[edit | edit source]

Regulation of rehabilitation professionals aims to protect the public and reduces the risks posed by rehabilitation professionals to cause physical or psychological harm to patients. Regulation also reduces the risks of causing adverse consequences as a result of interacting with health services. Regulatory systems promote professionalism and harm prevention. They ensure that rehabilitation professionals have been certified at meeting and continuing to meet educational, ethical and professional practice standards, therefore, protecting the health and safety of the public.[7] Regulation of rehabilitation professionals varies significantly around the world, depending on both the country and the specific profession (i.e. physiotherapy, occupational therapy etc.).[7] If rehabilitation professionals are working in disaster and conflict settings outside of their own country of practice, they have a responsibility to register with the National Regulatory Authority, where it exists, and work within existing legislative and regulatory frameworks in that country. They must also ensure they have valid professional liability/indemnity insurance for the work they are undertaking.[7][8] If travelling as part of an emergency medical team for shorter term deployments, rehabilitation professionals may often be required to follow regulation by both their own regulatory body and that of the country they are travelling to work in, and should ensure they meet whichever regulation is tighter.

Despite facing overwhelming needs within humanitarian settings, it is vital that rehabilitation professionals maintain appropriate levels of practice. All rehabilitation professionals require profession-specific clinical knowledge to assess patients who need or would benefit from rehabilitation services. All professionals share the same requirement of having the knowledge, skills and ability to implement evidence-based interventions and management programmes that are patient-centered while also monitoring, adapting, and redesigning intervention plans based on the patient’s needs and response to care. Rehabilitation professionals have a responsibility to follow the professional standards and standards of practice around competence, knowledge, skills and personal, social and methodological abilities, and the standards of professional conduct as defined by the relevant regulatory authority. This helps to ensure that clinical practice is safe and effective.[7] [9][10]

Eight core professions offer rehabilitation services: audiology, occupational therapy, psychology, physical and rehabilitation medicine, physiotherapy, prosthetics and orthotics, rehabilitation nursing and speech-language pathology. Each rehabilitation profession has developed its own international and/or national frameworks to guide professional standards and standards of practice. These frameworks or guidelines communicate professional standards, support education, guide curriculum planning, guide development, and help to establish individual and service-wide development priorities.[11] Rehabilitation professionals should also include wider humanitarian-specific professional standards, such as the humanitarian principles outlined above, and the Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams[2] to ensure their practice meets the professional and ethical standards required when working in humanitarian settings.

The Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams outlines the following standards and recommendations in relation to regulation and professionals standards in emergencies.

  • Recommendations for Optimal Care;
    • All rehabilitation professionals should comply with the same requirements for practice as in their home country (such as professional registration and licensing) and should work within their scope of practice.
    • Those from countries in which there is no professional certification may practice under the direction and authority of their Emergency Medical Team Clinical Lead with approval of the Ministry of Health of the Host Country.[3]

Scope of Practice[edit | edit source]

Scope of practice pertains to the full spectrum of roles, functions, responsibilities, activities and decision-making capacity that individuals within their specific rehabilitation profession are educated, competent and authorised to perform.[12] While this can be broad for each profession, each individual will need to consider their own scope of practice - this is unique to each individual and is influenced by their career, experience and development.[13] Working in humanitarian settings such as disaster and conflict zones can be very challenging and rehabilitation professionals are often pushed towards the boundaries of their individual scope of practice. Despite these challenges, it is vital that all rehabilitation professionals remember their responsibility to work within their own individual scope of practice at all times, and should only practice within areas where they have the skills and competency to safely work.

Advanced or extended scope practitioners sometimes undertake additional tasks that are outside of what would normally be considered within the scope of practice for a particular profession. Rehabilitation professionals who have an extended scope of practice or advanced practice have an obligation to only work within the scope of practice for their profession as defined by the regulatory body within the country they are working in (if there is one present). They must only participate in their advanced practice if allowed within the setting in which they are working and where their insurance provides cover. Rehabilitation professionals may also have a role to play in working with national staff to support them in developing further skills and competencies, within the scope of practice as defined by the country in which they are working.[8][9][10]

The Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams outlines the following recommendations in relation to scope of practice and knowledge exchange in emergencies.[3]

  • Recommendations for Optimal Care;
    • Rehabilitation professionals should maximize opportunities to exchange rehabilitation knowledge and competencies with local personnel ensuring that training of local rehabilitation workers should be consistent with local practice; and acknowledge local rehabilitation standards.[3]

Ethical Practice[edit | edit source]

Ethics in health care and rehabilitation can be defined as the moral code of conduct that defines the relationship between the rehabilitation professional and their patient, and the therapist and other healthcare professionals based on mutual respect and trust. Ethical issues emerging in disasters have been identified as tensions between the respect for local customs and values imposed by external responders; different understandings of health, illness and diseases; external factors that hinder the provision of adequate care, such as scarce resources; questions of a “moral identity” for health workers; and trust and distrust between the humanitarian workforce and local communities. Professionals’ roles and interactions are influenced by historical, political, social and commercial structures, aid agency policies and agendas that can contribute to ethically challenging situations. Ethical issues can also arise on the level of the patient-healthcare professional relationship.

You can read more about Ethics and Ethics in Disasters and Conflicts.

Medical Records[edit | edit source]

Good clinical records are a prerequisite of delivering high-quality, evidence-based healthcare, particularly where multiple clinicians are contributing simultaneously to patient care. Where possible in humanitarian settings, a common data set should be agreed between key providers to help standardise documentation. Everyone involved in a patient’s clinical management should have access to the information they need. Otherwise, duplication of work, delays and errors are inevitable. This can often occur in disaster and conflict settings where documentation and medical records may be neglected. Ideally, rehabilitation documentation should be integrated into a patient's main medical records. However, this may not always be possible in disaster and conflict settings. Moreover, all documentation should meet the guidelines as set out by the relevant rehabilitation professional regulatory authority.[15] Regardless of the setting, all medical records and data should be stored safely, securely and separate from other types of personal data, ensuring confidentiality for the patient at all times with plans made on how they will be handled in the event of an emergency evacuation.[11][3][1][2]

There is some dispute and controversy over ownership of medical records in humanitarian settings. Thus, to ensure continuity of care, the Classification and Minimum Standards for Emergency Medical Teams suggest that patients should be able to take a copy of their medical records, while also maintaining a central record. In some situations, there may also be a requirement for local medical authorities to also be provided with a duplicate record. However, in insecure and conflict environments, care should be taken to only identify patients using a numerical identifier, and where possible, only provide de-identified data to protect patients. Regardless of the setting, any data should be stored safely and securely, ensuring confidentiality.[3][1]

The Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams outline the following recommendations in relation to medical records and documentation in emergencies.[3]

  • Recommendations for Optimal Care;
    • Notes on rehabilitation, including interventions, assessments and assistive devices, should be incorporated into the patient’s main health record, which should remain with the patient when they are referred or discharged (in accordance with the minimum standards for Emergency Medical Teams. [3][16]


The Classification and Minimum Standards for Emergency Medical Teams outline the following minimum technical standards in relation to medical records and documentation in emergencies during triage, referrals and transfers and in ward management;[1]

  • Minimum Technical Standard
    • Triage
      • A unique identifier system should be in place that considers patient follow-up care and protection issues.
    • Referral and Transfer
      • Establish a standardized form and system for patient referral and transfer including formal handover between the transferring and receiving Emergency Medical Team / Health Facility.
      • Share information in a written document on patient's clinical condition, current treatment, intention to transfer, mode and timeline of transfer.
    • Ward Management
      • Provide documented discharge planning and follow-up care
      • Hand out a discharge document/copy of patient record to the patient.[1]

You can read more about Medical Records and Documentation

Informed Consent and Confidentiality[edit | edit source]

Informed consent refers to the patient's right to be informed about their condition, and the risks and benefits of treatment options. Informed consent is based on the moral and legal premise of patient autonomy, whereby a patient’s decision to participate in assessment, evaluation, diagnosis, prognosis, plan, treatment and re-examination, as well as in any research activity, is freely given by a competent individual. This individual should:[17]

  • Have received the necessary information;
  • Have adequately understood the information;
  • And after considering the information, have arrived at a decision without having been subjected to coercion, undue influence, inducement, or intimidation.[17]

The principle of confidentiality is about privacy and respecting someone’s wishes. It means that rehabilitation professionals should not share personal details about someone with others, unless that person has said they can or it is absolutely necessary. Patients/clients have the right to confidentiality. Any information related to health status, diagnosis, prognosis, interventions/treatment or any other personal information obtained from them should be kept in confidence unless explicit consent is given or the law specifically states otherwise.[18]

Informed consent is an essential element of a good patient-rehabilitation professional relationship and ensures a patients' rights are respected. It requires rehabilitation professionals to include their patients in the clinical reasoning process to reach a shared decision. Communicating clinical information effectively and educating patients are correlated with compliance with treatment and cooperation.[19]

Rules and regulations around informed consent and confidentiality may vary from one country to another. In some circumstances, rehabilitation professionals will find themselves challenged by the available resources, culture and the patient's capacity to make their own decisions. Despite this, humanitarian principles and the principles of informed consent and patient confidentiality are vital at all times during emergencies. The Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams for informed consent apply in emergency settings, and rehabilitation professionals should also consider the standards for informed consent as outlined by their professional regulatory authority.[1]

The Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams outlines the following standards and recommendations for informed consent in emergencies.[3]

  • Communicate benefits and risks involved prior to transfer and obtain written and informed consent from patient or relatives.

You can read more about Informed Consent.

Research[edit | edit source]

Research and collection of data to guide future responses is vital to further improve rehabilitation preparedness and responses in humanitarian settings. Maintenance of patient confidentiality during data collection processes must always place patient care and dignity above any research purposes. Rehabilitation professionals should ensure that all research has ethics approval, and where possible this should come from a local research ethics committee or authority within the country where the research is taking place.[8][10][3][1][2]

The Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams outlines the following standards and recommendations for research in emergencies.[3]

  • Minimal Technical Standard:
    • Ethical standards for research with human participants should be maintained in emergency response, especially in regards to permission and confidentiality.[16][20] [21]
  • Recommendations for Optimal Care:
    • Clinical care should take priority over research, which itself should be focused on improving the delivery and outcomes of rehabilitation.
    • People conducting research should collaborate with local academic institutions and undertake to build national capacity.
    • When local partners are involved, they should share the leadership of the project and ownership of the data.[3]

You can read more about Qualitative Research and if you interested in learning more about completing research, you can complete the Physioplus Research Programme.

Resources[edit | edit source]

Regulatory Bodies[edit | edit source]

National Regulatory Bodies, World Physiotherapy

Reciprocity - Mutual Recognition, World Physiotherapy

National Regulatory Bodies, World Federation of Occupational Therapists

Professional Standards[edit | edit source]

Standards of Practice, World Physiotherapy

Ethical Practice[edit | edit source]

Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies, World Physiotherapy

Code of Ethics, World Federation of Occupational Therapists

Medical Records[edit | edit source]

Physical Therapy Records Management: Record Keeping, Storage, Retrieval and Disposal, World Physiotherapy

Informed Consent[edit | edit source]

Informed Consent, World Physiotherapy

Research[edit | edit source]

Research, World Physiotherapy

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 World Health Organisation. Classification and minimum standards for emergency medical teams. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO.
  2. 2.0 2.1 2.2 2.3 2.4 A guidance document for medical teams responding to health emergencies in armed conflicts and other insecure environments. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO.
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 World Health Organization (WHO). Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams. 2016
  4. 4.0 4.1 World health Organisation, Chapter.1 Humanitarian Principles and International Humanitarian Coordination Mechanisms. In Health Cluster Guide: A Practical Handbook. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.
  5. Programme Learning Journey. Humanitarian Principles. Available from: https://youtu.be/EVKZACIndP4[last accessed 20/03/22]
  6. Sphere. Humanitarian Standards in Context. Available from: https://youtu.be/xuqFG1Fm1vw[last accessed 20/03/22]
  7. 7.0 7.1 7.2 7.3 World Physiotherapy. Development of a System for Regulation of the Physiotherapy Profession. World Physiotherapy; July 2021. Available from https://world.physio/guideline/regulation-legislation [Accessed 11 March 2022]
  8. 8.0 8.1 8.2 Lathia C, Skelton P, Clift Z. Early Rehabilitation in Conflicts and Disasters, 2020.
  9. 9.0 9.1 Skelton, P, and Harvey, A. Rehabilitation in Sudden Onset Disasters.Humanity and Inclusion; 2015.
  10. 10.0 10.1 10.2 World Confederation for Physical Therapy. WCPT Report: The Role of Physical Therapists in Disaster Management. London, UK: WCPT; 2016
  11. 11.0 11.1 Mills JA, Cieza A, Short SD, Middleton JW. Development and validation of the WHO Rehabilitation Competency Framework: a mixed methods study. Archives of Physical Medicine and Rehabilitation. 2021 Jun 1;102(6):1113-23.
  12. World Physiotherapy. Policy Statement: Description of Physical Therapy. World Physiotherapy; May 2019. Available from: https://world.physio/policy/ps-descriptionPT [Accessed on 7 March 2022]
  13. Chartered Society of Physiotherapy. What is Scope of Practice. Available from https://www.csp.org.uk/professional-clinical/professional-guidance/scope-practice/what-scope [Accessed 3 March 2022]
  14. UCSF IPE Program. Module 2, Segment 3: Scope of Practice. Available from: https://youtu.be/bZ2hPw8Zai0[last accessed 03/03/22]
  15. Eaton G. Documentation: are we writing it right?. Journal of Paramedic Practice. 2014 Sep 2;6(9):470-5.
  16. 16.0 16.1 Norton I, von Schreeb J, Aitken P, Herard P, LaJolo C. Classification and minimum standards for foreign medical teams in sudden onset dIsaster. Geneva: WHO; 2013.
  17. 17.0 17.1 World Physiotherapy.Policy Statement: Informed Consent. May 2019. Available from https://world.physio/policy/ps-consent [Accessed on 09 March 2022]
  18. World Physiotherapy. Policy Statement: Patients’/Clients’ Rights in Physical Therapy. May 2019. Available from https://world.physio/policy/ps-patients-rights [Accessed 12 March 2022]
  19. Parry RH. Communication during goal-setting in physiotherapy treatment sessions. Clinical rehabilitation. 2004 Sep;18(6):668-82.
  20. World Medical Association. World Medical Association Declaration of Helsinki : Ethical Principles for Medical. Research Involving Human Subjects. J Am Med Assoc 2013; 310:2191–2194.
  21. Council for International Organizations of Medical Sciences, World Health Organization. International ethical guidelines for biomedical research Involving human subjects. Geneva:World Health Organization; 2002