In a qualitative study, Diane Playford and colleagues explore the views of health professionals who use goals and goal-setting within a rehabilitation context. This study was carried out with a group of health professionals working in rehabilitation in a variety of contexts - elder care, inpatient and community-based teams, as well as health care educators and researchers who had a clinical perspective.
As I’ve been pointing out over the past couple of posts, while goal-setting is used commonly amongst health professionals, it really is a bit of an unknown in terms of how goals are set, whether they are effective, who should set them, and whether patients should set their own - after they’ve been shown how to. Health professionals are almost characterised by their use of goals and goal-setting (Wade, 1998), but there are huge differences between professions and within different health care teams about how to go about setting goals, and who is involved in that process.
In this study, the 18 participants described their goal-setting processes. Four different methods were described by the participants:
A client-centred, handicap-based method of goal-setting in which short-term objectives are specified which contribute to an aim that can be achieved by discharge. A ‘Life goals’ questionnaire is first administered, then goals set and re-evaluated throughout the admission.
An assessment-based process using formal functional disability measures, team discussion about the person’s needs and then goals are set. This team clearly distinguishes between explicit goals articulated by the person and needs identified by the team which may not be made explicit but are felt to be in the person’s best interests. This goal-setting process may extend over 18 months.
Another team assess impairments, disabilities and handicaps, and a long-term goal is set including a date of discharge. This goal is essentially a statement of the expectation of what functional level will have been achieved by discharge. Short-term goals are regarded as stepping stones on the way to the long term goal, action plans refer to team actions, while goals are what the patient is expected to do.
The final goal-setting process is the one I described a couple of days ago, where patients set their goals within six functional areas, describing what they want to do and what they need to do, and what they can do.
An interesting finding from this discussion was that many of the health professionals set their own life goals, but didn’t think that many of their patients routinely did. ‘It was felt common to have short-term objectives, such as ‘This morning I’ll get the shopping’, and loose ambitions, such as ‘When I’ve got a new job I’ll move to a better house’,’ these goals weren’t thought to be described in the terms that health professionals typically use in therapy such as ‘I will attend three exercise classes every week for five months to be able to lose 10 kg.’
Does this sound familiar? In fact, like the authors of this study, the people I’ve worked with don’t routinely set goals and if or when they do, the goals represent an opportunity to fail - rather than an acheivable rewarding activity, goals are seen as something to fear.
Goals in a health care setting are usually based on what the client/patient cannot do - impairments, disabilities, deficits. In some settings, health care teams may suggest the activities a person cannot achieve are ‘replaced’ by substitute activities. Without good knowledge of the person (which comes from spending time with them), these substitute activities can be completely inappropriate. Playford, in this paper, suggests that health professionals need to spend at least an hour with the person to get to know what their priorities and life roles are (Playford et al. 1999).
These teams worked primarily within a hospital or health care context, rather than the home environment of the patient. Participants in the workshop indicated that they thought goal-setting was particularly hard to do in this setting, especially if the person had only just recently sustained a life-changing disability. ‘ Goal-setting was thought to be only relevant to patients with low anxiety levels and when they had a vision of themselves and their future.’. Interestingly, Playford and colleagues state ‘Patients with chronic disability who start the process of goal-setting as outpatients and in whom admission is seen as a way of achieving a specific goal were seen to have more appropriategoals and higher satisfaction with the process.’
As I reflect on this, I find that people with long-term chronic pain often lose sight of their goals, and after having participated in developing rehabilitation plans with a case manager who seems to focus primarily on ‘return to work’ as a goal, the people I work with haven’t considered what they really want from rehabilitation. As a result, to think of specific goals is incredibly difficult - and anxiety-provoking - and because they don’t have ‘a vision of themselves and their future’ it takes some time before they can begin to consider what is possible. And they expect not to achieve what they set out to do, because they don’t experience an awful lot of success within therapy that translates to the everyday world.
Who owns the goals? Who’s goals are they anyway? Good question. From this study it was found that teams believed in the importance and benefits of goals being ‘owned’ by the patient, but found challenges in terms of actually making this happen. This study identified that ‘Patients with acute onset disability have to come to terms with their difficulties. The team do not have to adjust emotionally and can therefore identify many of the problems rapidly and clearly.’ In addition, ‘Teams tend not to acknowledge patient goals that they are unable to deal with.’ The study participants also noted that teams may identify goals that don’t necessarily align with what the patient identifies as a priority - but patients are less likely to disagree with the team’s agenda. And finally, these study participants thought that team goals help teams work more effectively - coherently and productively. Where is the patient in this?
In the discussion in this paper, the authors indicate that ‘goal-setting may be seen as owned by professionals, performed for their benefit in a context that is not sensitive to the patient needs. This may be because goal-setting is often tied to the assessment process which legitimately addresses pathology, impairment and disability as well as handicap and is clearly professionally owned.’ They go on to suggest that a menu approach to identify appropriate in-patient goals might be helpful, although these may not identify important ‘life plan’ goals such as emotional stability, resumption of life roles, and other personally-relevant activities that patients may not be able to articulate.
In my practice, we have a little more time to work with people to set goals, but it continues to be challenging. And there is a tension between the therapeutic priorities - eg this person needs to learn this skill - and real-world goals relevant to the individual - eg I want to get better sleep. Therapeutic priorities need to be subordinate to real-world goals, but can become an end in themselves rather than a means to an end. And if we don’t spend time with our clients, or we have a specific agenda, or we don’t listen very carefully, or if our clients have become so demoralised that they can’t see beyond today’s self care goals, then it’s going to be difficult to help people set goals that are important and relevant in their daily lives.
I think we also need to ask ourselves: do we routinely use goals? Do we write them down and the formula we expect patients to use? Or do we instead set a general trajectory and make plans to carry out actions that we hope will take use where we want to be? Are we expecting more from our patients than we do ourselves? Do we know how to set and use goals effectively for ourselves? What is the best way to set and monitor a goal in the real world as opposed to a clinic?
E.D. Playford, L. Dawson, V. Limbert, M. Smith, C.D. Ward, R. Wells (2000). Goal-setting in rehabilitation: report of a workshop to explore professionals’ perceptions of goal-setting Clinical Rehabilitation, 14 (5), 491-496 DOI: 10.1191/0269215500cr343oa
Wade DT. Evidence relating to goal planning in rehabilitation (editorial). Clin Rehabil 1998; 12: 273–75.