The benefits and challenges of interdisciplinary, client-centred, goal setting in rehabilitation.
This article provides insights into the benefits and challenges of interdisciplinary, client-centred, goal setting in rehabilitation as drawn from both recent literature and the author's clinical experiences. The article first considers the support for goal setting in rehabilitation as demonstrated through national and international policies. It will then extract themes from literature outlining the benefits of goal setting for client participation and motivation, interdisciplinary working, improving communication and improved outcomes. This will be followed by a discussion of the challenges and barriers to goal setting. In addition it will outline how a goal setting process could be established within a rehabilitation environment.
Goal setting, interdisciplinary team, rehabilitation
I have worked as an occupational therapist in a range of rehabilitation settings both in the UK and New Zealand, the past 5 years being predominantly stroke rehabilitation--acute, inpatient and community. Accordingly, my experience has lead to my being involved in establishing interdisciplinary, client-centred goal setting processes within an Intermediate Care Centre and an Older Persons Health rehabilitation service. These projects emerged from the belief that such a process would improve the experience and outcomes of clients and create a more collaborative working environment for the team. Collaborative practice is not a new concept for occupational therapists. The involvement of clients and their relatives in models of practice, treatment planning and prioritising intervention has appeared in occupational therapy literature for over a decade (Canadian Association of Occupational Therapists, 1997). However the idea of a collaborative, interdisciplinary approach to goal setting tends to be more complex as it involves more professionals from a range of health care backgrounds, and raises questions of role responsibilities, role boundaries and role blurring (Conneeley, 2004). The terms multidisciplinary and interdisciplinary are often used interchangeably (Mandy, 1996) and have been described as a group of people, trained in the use of different tools with an organised division of labour, all working towards a common goal. There is group responsibility for the final outcome (Mandy, 1996).
In this article a goal is defined as "the state or change in state that it is hoped or intended for an intervention or course of action to achieve" (Wade, 1999a, p. 8). Goal setting here refers to the identification of, and agreement on, a target which the client, therapist or team will work towards over a specified period of time for the purpose of rehabilitation (Royal College of Physicians, 2004). Alternatively, McLellan (1997) defined rehabilitation as "a process of active change by which a person who has become disabled acquires the knowledge and skills needed for optimal physical and psychological function" (p. 1). This definition acknowledges that rehabilitation involves a client-focused process in which the client is actively involved, thereby supporting client-centred practice.
Client-centred goal setting is considered 'best practice' in rehabilitation. This approach is advocated in a range of rehabilitation literature; however it tends not to be implemented because people are unsure how to go about it. In my experience, it appears that once people have established how, goal setting is slow to be implemented because staff are unsure why they are doing it.
This article aims to consider these two issues by presenting evidence from relevant literature and drawing on personal clinical experience. Firstly, reasons for goal setting in rehabilitation as demonstrated by national policy and themes from the literature are considered to outline the effects of goal setting on increasing client involvement, rehabilitation as a partnership, client motivation, implications for the interdisciplinary team, improving communication and improved outcomes. Some of the challenges and barriers to goal setting as documented in recent literature and experienced in clinical practice will also be discussed. Secondly, the steps required to achieve a goal setting process within a rehabilitation environment are outlined. This process uses 'life goals' (Sivaraman Nair, 2003) as a basis for establishing client's priorities. Lastly, exemplars of processes which have been used successfully in clinical practice are provided to illustrate interdisciplinary goal-setting practice.
According to the model of clinical decision making outlined by Rappolt (2003) there are three types of evidence used by occupational therapists to guide practice. These include: professional expertise, research evidence and client evidence. This article will draw on evidence for goal setting to enhance rehabilitation using only the first two of these, as first hand experience of client evidence has been on an informal level.
Policy and legislation
Numerous New Zealand national policy documents and professional bodies have issued statements about the use of goals in client care and rehabilitation. The Guideline for Specialist Services for Older People (Ministry of Health, 2004) states that "Services will focus on enabling older people to identify and achieve their own health and independence goals" (p. 14). The document also recommends the building of interdisciplinary teams which will operate within a holistic framework to develop rehabilitation plans in collaboration with the older person, their family/whanau and appropriate others. In keeping with this vision the Life After Stroke: New Zealand Guideline for Management of Stroke (Stroke Foundation, 2003) states that "rehabilitation should be goal focused and occur in an appropriate cultural and environmental context" (p. 47).
Likewise the Occupational Therapy Board of New Zealand: Code of Ethics (2004) and The New Zealand Society of Physiotherapists: Standards of Practice (2006) both dictate that therapists should work in conjunction with consumers to formulate functional goals and involve significant others of the consumer's choice. In the United Kingdom policy appears to have gone one step further in dedicating full sections of their guidelines to the subject of goal setting as found in the Royal College of Physicians, National Clinical Guidelines for Stroke, section 2.4.2 (2004).
Similarly, the World Health Organisations framework for health and disability, the International Classification of Functioning, Disability and Health, (2001), has influenced a change in how we view and plan health care provision at the individual, institutional and social levels. There has been a move away from the traditional medical and social models of disability to a model where health is seen as individuals' ability to interact with their environment and participate in desired activities. The general principles from each of these documents are that health care professionals should be working as a coordinated team with clients to elicit individual goals and ensure that the treatment plans are consistent with the client's goals.
Rehabilitation involves a client focused journey in which the client must take an active part (Holliday 2004). There is no doubt that the process of goal setting can provide an ideal opportunity for a client to engage in their rehabilitation experience. Goals are more important to a person when they have participated in creating them, as there is some responsibility and ownership for the attainment of the goal (Holliday, 2004). For that reason, it would seem self efficacy enhances goal commitment. This is consistent with the findings of Conneeley's (2004) qualitative study designed to explore the use of collaborative goal planning from the perspectives of the professional staff, clients and relatives. Data reveals "involvement in the process of goal setting appeared to act as a strong motivator to engage in therapy" (p. 251). In addition, Conneeley (2004) advocates that therapists should begin to see themselves more as collaborators and facilitators rather than imposers of rehabilitation.
Negotiating rather than imposing goals can have implications on client compliance and motivation. As therapists we can provide the information to enable informed choice. We bring the professional expertise and the client brings the experience of disability. The process of developing a partnership between the therapist and client begins with building rapport. The therapist may provide more input in the initial stages however as the process develops, the client takes on more responsibility (Sumsion, 2004). Goals should be seen as increasing clients' empowerment and control, ownership of treatment and confidence. If the aim of rehabilitation is to increase independence and reclaiming control (Wade, 1999a), then encouraging active participation in decision making is an important concept if clients are to achieve long term independence.
The impact on the interdisciplinary team
My experience has taught me that client-centred goal setting provides a clear focus for the interdisciplinary team and assists in creating opportunities for communication and collaboration. Having the focus move away from the goals of each individual discipline to those of the client also has an effect on reducing conflict within a team. Client centred goals allow for the statement and formulation of common objectives increasing team motivation and enabling the evaluation of outcome (Holliday, 2004).
Although this concept has not been very well addressed in recent literature there is a belief that goal setting will lead to role overlap and a blurring of professional boundaries. This is perceived as a threat by some professionals and is an issue which has been a recurring theme in workshops and groups facilitated by the author when establishing goal setting within rehabilitation services. Although the issue may initially appear to be relevant, if action plans are well documented and communicated at team meetings it has been found that duplication of roles is prevented and individual therapists specialised knowledge is respected.
Time is often a factor which is mentioned within the literature as a constraint to client-centred goal setting. Time is necessary so clients can discuss and explore their goal options. Once goals are set, time is required to receive feedback and explain the progress related to those goals. In most busy rehabilitation services time is already a precious resource and some interdisciplinary teams are reluctant to give up more time on what may be viewed as inactive therapy. The author argues there is no point in continuing with active therapy if the client has no interest in the activity or outcome, and no motivation to participate. Therapists are more likely to influence change if the client is engaged, motivated, and has confidence in achieving a functional outcome to the therapy in which they are participating. The time spent in the initial stages of goal setting is saved later through the benefits of meaningful engagement in rehabilitation.
The aforementioned opinion is reflected in Sumsion's (2004) study which addressed the effects of pursuing client centred goals in a community mental health service. One finding from this study was that clients were seen less and less when their goals were clearly established and they were working towards them. Time was wasted when the therapists were too prescriptive because this meant the goals lacked meaning to the client.
Randall and McEwen (2000) linked the writing of client-centred functional goals to motor learning (relearning) research which supports a focus on functional limitation and disability-related goals. From a motor learning perspective, clients who are undergoing physical therapy are learners who must analyse tasks and develop effective, personally suited motor strategies for performing the tasks under varying environmental conditions (Carr, & Shepherd, 2000). Goals and subsequent treatments that address the environments in which clients want to engage as a result of therapy optimises their potential to do these activities successfully following discharge (Randall, & McEwen).
Improved communication between client, relatives and team
Wade (1999b) emphasises that the first step in goal setting is to establish or at least to consider the expectations of all those involved: the client; their relatives, and the individual team members. Often the client's expectations are for a full recovery but they may develop new expectations based on experiences. For example, the nurses will feed me and help me to wash, the doctor will decide when I can go home. The nature of these new expectations will depend on the client's previous experiences of health care, their cultural expectations and the experiences of friends and relatives. Equally client's families, who may be directly involved in providing care and financial support, will themselves have their own experiences and expectations of the service. Consequently every client and every family will come to rehabilitation with a system of beliefs concerning their illness. These beliefs are unlikely to concur with the beliefs held by the rehabilitation team (Wade, 1999b).
Goal setting therefore provides an opportunity for these expectations to be identified and discussed. It is not for the therapists to make assumptions about what these expectations may be as often assumptions are incorrect. In the authors experience the process of client-centred goal setting provides a number of communication methods in the early stages which can lead to a better understanding of the service, the client, their lives, their relationships and their environment. The process provides for open communication and encourages therapists to include family members. The fact that they are drawn in earlier leads to less conflict in the later stages. Ways of establishing communication links during goal setting to establish, and perhaps alter, expectations will be discussed later.
Goals associated with outcome measures
The outcomes of rehabilitation interventions are commonly rated by disability scales such as the Barthel Index and the Functional Independence Measure. While these are useful outcomes they also have inherent drawbacks and do not reflect aspects of client participation. There is a need for more client-centred goal based outcome measures which will provide information complimentary to the measurement of disability, especially in cases where little quantifiable disability change arises, and when ceiling or flooring effects occur with a rating scale (Liu et al., 2004).
A number of goal based outcome measures are available. For example Goal Attainment Scaling (Weidenbohm, Parsons, & Dixon, 2005), Canadian Occupational Performance Measure (Law et al, 1994) and the Self Identified Goals Assessment (Melville, Baltic, Bettcher, & Nelson, 2003). Each of these measures are based on a similar concept of setting client-centred goals and measuring the attainment or variances for non attainment, giving information to service users and providers on the success of rehabilitation programmes for meeting the individual needs of clients.
Challenges of goal setting
The most common challenge cited in literature and experienced by the author are the issues involved with clients who have severe communication difficulties, cognitive difficulties or poor insight. Previous experience indicates goal setting has been manageable for some of these clients as long as information is presented in an appropriate way and is meaningful to the individual. For instance, using supported communication strategies such as picture cards to represent a particular daily activity and then categorising the pictures into levels of importance. People with poor insight who set clearly unrealistic goals are supported by the process because it allows those involved to address the issue. Unrealistic expectations can then be challenged and through focusing on more short term attainable goals, a positive outcome can be achieved.
When an individual client can not make his or her goals known, a client representative may be able to develop targeted outcomes with the therapist (Canadian Association of Occupational Therapists, 1999). This concept was discussed by Conneeley (2004) who identified that often this role is assumed by a relative, who has an intimate knowledge of the client within the context of their own life. However, as identified by Sivaraman Nair (2003), relatives may also have an agenda which could be different to that of the client and therefore may be biased. In such an instance should a member of professional staff assume this responsibility? Professional staff may have a preconceived idea of good and bad outcomes but equally this may be different to that of the client. These issues which are common in the rehabilitation process are not easily addressed in relation to goal setting.
When introducing the concept of goal setting to clients and their relatives it is useful for therapists to be aware of their understanding of the word 'goal'. Although some authors believe the term is becoming a more familiar concept in aspects of peoples daily lives (Conneeley, 2004) and should, therefore be a simple concept for people to grasp, other authors stress that therapists need to be cautious as the word 'goal' is quite non-specific and can be perceived quite differently by health professionals and the general public (Holliday, 2003).
It is interesting to note that the confusion over terminology is not only confined to therapist and client. In the initial stages of planning a goal setting process for a stroke rehabilitation unit, one professional from each discipline was involved in deciding the terminology to be used. Each professional had their own preferences for the use of the words: aim, goal, objective, target and action. Obviously this is an issue which needs to be addressed within a team to ensure all members are using the same terminology and clients are not confused by differing expectations.
There is evidence which suggests members of the interdisciplinary team need education in eliciting clients' goals. In a recent study by Parry (2003), therapists' communication practices during goal setting in stroke rehabilitation were observed and analysed. Seventy four treatment sessions involving 21 clients and 10 therapists of varying experience were video recorded. Eight goal setting episodes were identified. In all but one, therapists supplied the target problems for which goals were subsequently set. In only one case was the client asked to identify problems prior to goal setting. The study found various interactional difficulties and delays arising both in eliciting the client's views and incorporating them into agreed goals. Strategies by which the therapist dealt with these difficulties included repeated and constraining questions, negotiation and amending proposed goals. The findings of this small detailed study support the author's experience, and observations, of poor collaboration in goal setting and failure to maximise client involvement. Goal setting, especially where client's views are elicited and incorporated, involves skill and effort. Developing this skill requires education, guidance through supervision and professional practice.
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A challenge which has been highlighted during questions following training sessions lead by the author is that of appropriate timing to begin goal setting with clients. There does not appear to be any definitive answer to this. A general rule is to wait until each member of the interdisciplinary team has completed their assessment and the client has had enough understanding of their condition to make informed decisions. Both Conneeley (2004) and Sumsion (2004) agree that education and information giving facilitates better understanding and therefore more realistic goal setting. This initial intervention can take days or sometimes weeks.
The concept of life goals in rehabilitation
Life goals and their relation to rehabilitation have been outlined and reviewed in a number of recent articles (Boerner, & Cimarolli, 2005; Sivaraman Nair, 2003; Sivaraman Nair, & Wade 2003). These articles all describe life goals as the desired state that people seek to obtain, maintain or avoid, and an important motivational force which contributes to health and well being. The perception of progress towards life goals is related to improved well-being whereas absence or conflict of life goals is considered to lead to negative physical and psychological effects. Facing an acute or chronic illness often means the pursuit of life goals is disrupted or entirely blocked, resulting in emotional distress.
Sivaramen Nair (2003) conducted a review of literature on life goals and their influence on the rehabilitation process. Thirty nine articles directly dealing with the subject were included in the review. This review established that incorporation of a client's life goals into a rehabilitation programme resulted in better outcomes in various physical and psychological disorders. Several questionnaires were found to be available for the assessment of life goals with different questionnaires assessing different aspects of life. Only one of these questionnaires was found to have been tested for validity and reliability in a rehabilitative setting, this being the structured questionnaire and accompanying interview used by the Rivermead Rehabilitation Centre (now the Oxford Centre for Enablement).
The link between rehabilitation goals and life goals has an important effect on a client's motivation and subsequent success of therapy intervention. Subsequent to recognising this fact the author was involved in the development of two goal setting processes in different areas of rehabilitation. The processes are based on these concepts and adapted from the Rivermead Rehabilitation Centres original documentation (Wade, 1999b). Figure 1 outlines the process used within an Intermediate Care Centre for adults with stroke, neurological and general rehabilitation needs, and an Older Peoples Health rehabilitation ward based in an acute city hospital. The goal setting processes are designed to fit with the already existing structures of each of the two services so as to limit the amount of extra meetings and paperwork involved.
The left, linear, aspect of the flow chart represents the general client journey through the services prior to the addition of goal setting. The right side of the flow chart (those stages in italics) represents the added goal setting stages which were incorporated into the already established structure.
The initial admission and clerking in of the client to the ward remains the same and is predominantly undertaken by the ward doctor and nursing staff. Once or twice weekly interdisciplinary ward meetings are held and at the first of these the client is discussed in terms of their presenting condition and rehabilitation needs. The team then make a decision on which members will be involved, which professional is likely to be the most involved and therefore who will take the role of key-worker. For example, a client with severe communication difficulties would most likely have a speech and language therapist as their key-worker. The main role of this individual is to coordinate the goal setting process and liaise between all involved members to ensure streamlined communication routes.
During the first week or two of assessment the key-worker liaises with the client and their relatives to explain the process of rehabilitation within the service and the concept of goal setting. The key-worker then carries out a client questionnaire based on the life goals questionnaire developed by Rivermead Rehabilitation Centre (Wade, 1999b). The client is asked to consider 9 categories ranging from relationships to managing their finances, residential arrangements and personal care, while the key-worker records comments from the discussion. The client is also asked to rate the importance of each category on a scale of 0 (of no importance) to 3 (of extreme importance). Those areas which are rated as being of extreme importance are the areas which set a baseline for goal development. Clients are also asked about their expectations and wishes during their stay on the ward, this is incorporated into the same interview to allow for time constraints, unlike the Rivermead approach which uses two separate interview formats.
Likewise the key-worker makes sure family members are issued with a questionnaire asking for details of their expectations of rehabilitation and discharge. This questionnaire is based on the Rivermead Relatives Expectations and Wishes Interviews (Wade, 1999b) but uses a questionnaire which the family can take away with them and consider. This is preferable to an interview form which has to be completed with a member of staff present and perhaps be done under pressure.
Based on the information gained from the client interview and family questionnaire the key-worker forms an outline of likely rehabilitation goals and gives feedback to the team members involved with the person. An appointment may then be made for a family case conference where findings from the assessment period and priorities arising from the interview/questionnaire can be considered. The interdisciplinary team, client and relatives can discuss and agree to goals on which future rehabilitation will be based. Goals are documented on goal sheets with short-term action plans to meet each goal being formalised. These are kept in the client's rehabilitation care plan, preferably where they, themselves, can gain access to them.
The review of goal sheets can occur as appropriate for the individual. Goals are best reviewed at interdisciplinary ward meetings where all the team members can agree on the level of achievement and the next action to be documented on the action plan. Goal sheets can also be taken to individual treatment sessions to demonstrate achievement to the client and to provide a rational for the treatments being undertaken.
Discharge planning begins when goals are achieved or reasons for non-achievement are identified. It has been found that where previously a second family case conference was required at this point, the communication involved in the goal setting process means relatives feel more informed and are therefore less likely to request a second meeting with the team.
The author acknowledges that the process for establishing client-centred interdisciplinary goals is not suitable for every rehabilitation setting, especially those with fast stream services or professional teams based in different geographical areas. Nonetheless, some aspects of the process may be duplicated and adapted, which is what was done to fit the service provision in the environments described in this article. Further investigation of the client experience of goal setting is needed.
This article has considered the importance of interdisciplinary client-centred goal setting to the client, their relatives and the interdisciplinary team from the evidence in literature and the author's experience. Challenges of goal setting have been discussed and strategies to overcome them presented. A process for implementing goal setting based on the author's experience of two in-patient rehabilitation environments has been described and could be adapted to suit other rehabilitation environments and teams. The author hopes this information will help therapists who work in a rehabilitative service to improve their understanding of the concept and implementation of goal setting.
Setting client-centred, interdisciplinary goals will help to:
* improve client motivation by meeting the unique needs of the client
* improve communication between the team and relatives
* assist in creating stronger interdisciplinary working relationships
* conform to health policy and assist in meeting legislative requirements.
This article was accepted for publication on 25 March, 2007.
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Jonathan Armstrong, BSc (Hons) Occupational Therapy
Allied Health Dept, Level 11, Support Building
Auckland City Hospital
Private Bag 92189
Auckland Mail Centre
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|Publication:||New Zealand Journal of Occupational Therapy|
|Date:||Mar 1, 2008|
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