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The benefits and challenges of interdisciplinary, client-centred, goal setting in rehabilitation.



Abstract

This article provides insights into the benefits and challenges of interdisciplinary in·ter·dis·ci·pli·nar·y  
adj.
Of, relating to, or involving two or more academic disciplines that are usually considered distinct.


interdisciplinary
Adjective
, client-centred, goal setting in rehabilitation rehabilitation: see physical therapy.  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.

Key words

Goal setting, interdisciplinary team interdisciplinary team,
n a group that consists of specialists from several fields combining skills and resources to present guidance and information.
, rehabilitation

**********

I have worked as an occupational therapist occupational therapist A person trained to help people manage daily activities of living–dressing, cooking, etc, and other activities that promote recovery and regaining vocational skills Salary $51K + 4% bonus. See ADL.  in a range of rehabilitation settings both in the UK and New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. , the past 5 years being predominantly pre·dom·i·nant  
adj.
1. Having greatest ascendancy, importance, influence, authority, or force. See Synonyms at dominant.

2.
 stroke rehabilitation--acute, inpatient inpatient /in·pa·tient/ (in´pa-shent) a patient who comes to a hospital or other health care facility for diagnosis or treatment that requires an overnight stay.

in·pa·tient
n.
 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 A Collaborative Working Environment (CWE) supports people (e.g., E-professionals) in their individual and cooperative work. Research in CWE involves organisational, technical, and social issues.  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 In radiotherapy, Treatment Planning is the process in which a team consisting of radiation oncologists, medical radiation physicists and dosimetrists plan the appropriate external beam radiotherapy treatment technique for a patient with cancer. Typically, medical imaging (i.e.  and prioritising intervention A procedure used in a lawsuit by which the court allows a third person who was not originally a party to the suit to become a party, by joining with either the plaintiff or the defendant.  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 mul·ti·dis·ci·pli·nar·y  
adj.
Of, relating to, or making use of several disciplines at once: a multidisciplinary approach to teaching. 
 and interdisciplinary are often used interchangeably INTERCHANGEABLY. Formerly when deeds of land were made, where there Were covenants to be performed on both sides, it was usual to make two deeds exactly similar to each other, and to exchange them; in the attesting clause, the words, In witness whereof the parties have hereunto  (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 The Royal College of Physicians of London was the first medical institution in England to receive a Royal Charter. It was founded in 1518 and is one of the most active of all medical professional organisations. , 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 according to
prep.
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

3.
 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 guideline Medtalk A series of recommendations by a body of experts in a particular discipline. See Cancer screening guidelines, Cardiac profile guidelines, Gatekeeper guidelines, Harvard guidelines, Transfusion guidelines.  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 Holistic
A practice of medicine that focuses on the whole patient, and addresses the social, emotional, and spiritual needs of a patient as well as their physical treatment.

Mentioned in: Aromatherapy, Stress Reduction, Traditional Chinese Medicine
 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 TO DICTATE. To pronounce word for word what is destined to be at the same time written by another. Merlin Rep. mot Suggestion, p. 5 00; Toull. Dr. Civ. Fr. liv. 3, t. 2, c. 5, n. 410.  that therapists should work in conjunction with consumers to formulate formulate /for·mu·late/ (for´mu-lat)
1. to state in the form of a formula.

2. to prepare in accordance with a prescribed or specified method.
 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 guidelines,
n.pl a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks.
 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 International Classification of Functioning, Disability and Health, also known as ICF, is a classification of the health components of functioning and disability. , (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 e·lic·it  
tr.v. e·lic·it·ed, e·lic·it·ing, e·lic·its
1.
a. To bring or draw out (something latent); educe.

b. To arrive at (a truth, for example) by logic.

2.
 individual goals and ensure that the treatment plans are consistent with the client's goals.

Client involvement

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 former name of device management software from Wyse Technology, San Jose, CA (www.wyse.com) that is designed to centrally control up to 100,000+ devices, including Wyse thin clients (see Winterm), Palm, PocketPC and other mobile devices. . 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 em·pow·er  
tr.v. em·pow·ered, em·pow·er·ing, em·pow·ers
1. To invest with power, especially legal power or official authority. See Synonyms at authorize.

2.
 and control, ownership of treatment and confidence. If the aim of rehabilitation is to increase independence and reclaiming
For the neopagan organization of this name, see Reclaiming (neopaganism). For the reclaiming of land, see land reclamation.
To reclaim is to bring a word back to a more acceptable course.
 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 formulation /for·mu·la·tion/ (for?mu-la´shun) the act or product of formulating.

American Law Institute 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 professional boundary Professional ethics An ill-defined psychosocial 'frontier' maintained between a professional and a Pt or client. See Dual relationship, Sexual misconduct, Slippery slope. . This is perceived as a threat by some professionals and is an issue which has been a recurring re·cur  
intr.v. re·curred, re·cur·ring, re·curs
1. To happen, come up, or show up again or repeatedly.

2. To return to one's attention or memory.

3. To return in thought or discourse.
 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 duplication /du·pli·ca·tion/ (doo-pli-ka´shun)
1. the act or process of doubling, or the state of being doubled.

2.
 of roles is prevented and individual therapists specialised Adj. 1. specialised - developed or designed for a special activity or function; "a specialized tool"
specialized

specific - (sometimes followed by `to') applying to or characterized by or distinguishing something particular or special or unique; "rules with
 knowledge is respected.

Time is often a factor which is mentioned within the literature as a constraint Constraint

A restriction on the natural degrees of freedom of a system. If n and m are the numbers of the natural and actual degrees of freedom, the difference n - m is the number of constraints.
 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 in·ac·tive  
adj.
1. Not active or tending to be active.

2.
a. Not functioning or operating; out of use: inactive machinery.

b.
 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 mo·ti·vate  
tr.v. mo·ti·vat·ed, mo·ti·vat·ing, mo·ti·vates
To provide with an incentive; move to action; impel.



mo
, 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 a·fore·men·tioned  
adj.
Mentioned previously.

n.
The one or ones mentioned previously.


aforementioned
Adjective

mentioned before

Adj. 1.
 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 pre·scrip·tive  
adj.
1. Sanctioned or authorized by long-standing custom or usage.

2. Making or giving injunctions, directions, laws, or rules.

3. Law Acquired by or based on uninterrupted possession.
 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 re·learn·ing
n.
The process of regaining a skill or ability that has been partially or entirely lost.



re·learn v.
) 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 an·a·lyse  
v. Chiefly British
Variant of analyze.


analyse or US -lyze
Verb

[-lysing, -lysed] or -lyzing,
 tasks and develop effective, personally suited motor strategies for performing the tasks under varying environmental conditions (Carr CARR Carrier
CARR Customer Acceptance Readiness Review
CARR Carrollton Railroad
CARR Corrective Action Request and Report
CARR City Area Rural Rides (Texas)
CARR Configuration Audit Readiness Review
CARR Customer Acceptance Requirements Review
, & 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 CONCUR - ["CONCUR, A Language for Continuous Concurrent Processes", R.M. Salter et al, Comp Langs 5(3):163-189 (1981)].  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 Barthel index,
n.pr standard, well-validated assessment that measures functional outcomes, including independence in mobility and self-care. Commonly used in rehabilitation medicine.
 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 Quantifiable
Can be expressed as a number. The results of quantifiable psychological tests can be translated into numerical values, or scores.

Mentioned in: Psychological Tests
 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 Parsons, city (1990 pop. 11,924), Labette co., SE Kans.; inc. 1871. It is a shipping point for dairy products, grain, and livestock. Manufactures include ammunition, wire and paper products, plastics, and appliances. , & 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 at·tain  
v. at·tained, at·tain·ing, at·tains

v.tr.
1. To gain as an objective; achieve: attain a diploma by hard work.

2.
 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 Noun 1. preconceived idea - an opinion formed beforehand without adequate evidence; "he did not even try to confirm his preconceptions"
parti pris, preconceived notion, preconceived opinion, preconception, prepossession
 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 con·fine  
v. con·fined, con·fin·ing, con·fines

v.tr.
1. To keep within bounds; restrict: Please confine your remarks to the issues at hand. See Synonyms at limit.
 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 con·strain  
tr.v. con·strained, con·strain·ing, con·strains
1. To compel by physical, moral, or circumstantial force; oblige: felt constrained to object. See Synonyms at force.

2.
 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 e·lic·it  
tr.v. e·lic·it·ed, e·lic·it·ing, e·lic·its
1.
a. To bring or draw out (something latent); educe.

b. To arrive at (a truth, for example) by logic.

2.
 and incorporated, involves skill and effort. Developing this skill requires education, guidance through supervision and professional practice.

[FIGURE 1 OMITTED]

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 dis·rupt  
tr.v. dis·rupt·ed, dis·rupt·ing, dis·rupts
1. To throw into confusion or disorder: Protesters disrupted the candidate's speech.

2.
 or entirely blocked, resulting in emotional distress emotional distress n. an increasingly popular basis for a claim of damages in lawsuits for injury due to the negligence or intentional acts of another. Originally damages for emotional distress were only awardable in conjunction with damages for actual physical harm. .

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 Noun 1. psychological disorder - (psychiatry) a psychological disorder of thought or emotion; a more neutral term than mental illness
folie, mental disorder, mental disturbance, disturbance
. 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 re·ha·bil·i·tate  
tr.v. re·ha·bil·i·tat·ed, re·ha·bil·i·tat·ing, re·ha·bil·i·tates
1. To restore to good health or useful life, as through therapy and education.

2.
 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 neurological, neurologic

pertaining to or emanating from the nervous system or from neurology.


neurological assessment
evaluation of the health status of a patient with a nervous system disorder or dysfunction.
 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 In law, time constraints are placed on certain actions and filings in the interest of speedy justice, and additionally to prevent the evasion of the ends of justice by waiting until a matter is moot. , 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 Adj. 1. formalised - concerned with or characterized by rigorous adherence to recognized forms (especially in religion or art); "highly formalized plays like `Waiting for Godot'"
formalistic, formalized
. These are kept in the client's rehabilitation care plan, preferably pref·er·a·ble  
adj.
More desirable or worthy than another; preferred: Coffee is preferable to tea, I think.



pref
 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.

Conclusion

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 in·pa·tient or in-pa·tient  
n.
A patient who is admitted to a hospital or clinic for treatment that requires at least one overnight stay.
 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.

Key points:

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 Verb 1. conform to - satisfy a condition or restriction; "Does this paper meet the requirements for the degree?"
fit, meet

coordinate - be co-ordinated; "These activities coordinate well"
 health policy and assist in meeting legislative requirements.

Acknowledgement

This article was accepted for publication on 25 March, 2007.

References

Boerner, K., & Cimarolli, V. R. (2005). Optimizing rehabilitation for adults with visual impairment Visual Impairment Definition

Total blindness is the inability to tell light from dark, or the total inability to see. Visual impairment or low vision is a severe reduction in vision that cannot be corrected with standard glasses or contact lenses and
: Attention to life goals and their links to well being. Clinical Rehabilitation, 19,790-798.

Canadian Association of Occupational Therapists. (1997). Enabling occupation: An occupational therapy perspective. Ottawa: Author.

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1 City (1990 pop. 26,265), Johnson co., central Ind.; settled 1822, inc. as a city 1960. A residential suburb of Indianapolis, Greenwood is in a retail shopping area. Manufactures include motor vehicle parts and metal products.
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For the handbook about Wikipedia, see .

This article is about reference works. For the subnotebook computer, see .
"Pocket reference" redirects here.
. New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of
: Cambridge University Press Cambridge University Press (known colloquially as CUP) is a publisher given a Royal Charter by Henry VIII in 1534, and one of the two privileged presses (the other being Oxford University Press). .

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Northern, J. G., Rust, D. M., Nelson, C. E., & Watts Watts, residential section of south central Los Angeles. Named after C. H. Watts, a Pasadena realtor, the section became part of Los Angeles in 1926. Artist Simon Rodia's celebrated Watts Towers are there. , J. H. (1995). Involvement of adult rehabilitation patients in setting occupational therapy goals. The American Journal of Occupational Therapy, 49(3), 214-220.

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Involving or representing two or more colleges.

Adj. 1. intercollegiate - used of competition between colleges or universities; "intercollegiate basketball"
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Wade, D. T. (1999a). Goal planning in stroke rehabilitation: What? Topics in Stroke Rehabilitation, 6(2), 8-15.

Wade, D. T. (1999b). Goal planning in stroke rehabilitation: How? Topics in Stroke Rehabilitation, 6(2), 16-36.

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: Author.

Jonathan Armstrong, BSc (Hons) Occupational Therapy

Allied Health Dept, Level 11, Support Building

Auckland City Hospital The Auckland City Hospital is Auckland's main hospital and the largest hospital in New Zealand,[1] as well as one of the oldest medical facilities of the country. It is a publically funded hospital, run by the Auckland District Health Board since 2001.  

Park Road

Auckland

Private Bag 92189

Auckland Mail Centre

Auckland 1142

jonathan@adhb.govt.nz
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Title Annotation:VIEWPOINT
Author:Armstrong, Jonathan
Publication:New Zealand Journal of Occupational Therapy
Article Type:Report
Geographic Code:8NEWZ
Date:Mar 1, 2008
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