Service users' perceptions and experiences of goal setting theory and practice in an inpatient neurorehabilitation unit.
Goal setting is a key component in the rehabilitation process and
clinical guidelines recommend collaboration between health care
professionals, service users and their families. This qualitative
preliminary study (n = 6) used semi-structured interviews to explore the
perceptions and experiences of the goal setting process with service
users on a neurorehabilitation unit. Two overall themes emerged: the
components of goal setting and the factors that helped to guide the
process. The participants reported experiencing varying levels of
collaboration and concluded that goals should be achievable, realistic
and negotiated, yet challenging. Short-term goals were seen as
Goal setting, neurorehabilitation.
Goal setting (Health aspects)
Psychotherapist and patient (Management)
Therapist and patient (Management)
Occupational therapy (Methods)
Occupational therapy (Patient outcomes)
|Publication:||Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 College of Occupational Therapists Ltd. ISSN: 0308-0226|
|Issue:||Date: August, 2010 Source Volume: 73 Source Issue: 8|
|Topic:||Event Code: 200 Management dynamics Computer Subject: Company business management|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
Goal setting is the 'cornerstone of effective rehabilitation' (Lawler et al 1999, p402) and, over recent years, the evidence base for goal setting in rehabilitation has grown. However, there is no single clear guiding theory and in clinical practice there are many options for setting goals (Playford et al 2009). Patient and public involvement is high on the political agenda and current clinical recommendations also place the individual at the centre of the goal setting process (Department of Health 2005, Intercollegiate Stroke Working Party 2008); therefore, this study aimed to explore service users' perceptions of the key aspects of goal setting theory and practice.
In a summary of 35 years of empirical research on goal setting theory, Locke and Latham (2002) concluded that the process was complex and multifactorial. They highlighted the need for commitment to the goal, consideration of task complexity (Gauggel and Fischer 2001) and feedback. Neubert (1998) confirmed the power of goal setting and feedback in combination. Feedback holds two main functions: the primary role is to regulate the effort expended on a goal but there is also a role to evaluate the efficacy of the strategies. This study was with a 'normal' population, but highlighted the potential impact of feedback in combination with goal setting.
In relation to clinical practice, the focus of the goals must be activities that are meaningful to the individual in order to make the greatest impact and gains on functional performance (Randall and McEwen 2000). The process of goal setting has traditionally been seen as the domain of the multidisciplinary team (Holliday et al 2005).
Clinical experience suggests, however, that varying levels of collaboration exist between health care professionals, service users and their families in neurorehabilitation. The stroke survey by the Healthcare Commission (2006) reinforced this statement, because 59% of respondents felt that they wanted higher levels of involvement in the decisionmaking process around their care. Involving the family in the process has also been recognised to enhance cohesion with the multidisciplinary team (Conneeley 2004, Glazier et al 2004, Young et al 2008). Nevertheless, although recognising the importance of collaboration, Levack (2009) argued that professionals were bound to make best choice decisions with the available resources.
In order to use the goals to measure the effectiveness of rehabilitation interventions, the SMART concept (specific, measurable, achievable, realistic and timely) is recommended as a structure when setting goals (Edmans et al 2001). However, Bovend'Eerdt et al (2009) outlined a novel approach to goal setting, naming a framework that advocated identifying four key aspects: the specific activity, the support required, the level of performance and time.
Service users are reported to feel more positive about their ability to achieve short-term goals (Young et al 2008). They have been identified as particularly motivating in generating feelings of improvement (Manderlink and Harackiewicz 1984).
The evidence confirms Locke's and Latham's (2002) thoughts that goal setting is complex and multifactorial: there is no clear guidance for clinicians on the most effective process. This preliminary study sought to gather opinions from service users in order to identify their perceptions and experiences of this complex process.
The setting: The research was undertaken on a neurorehabilitation unit where service users participated in goal setting. The aims for rehabilitation were set in one-to-one sessions with service users and their key worker. The SMART concept was used by the clinicians to set long-term and short-term multidisciplinary goals, with input from the team and family as appropriate. Service users held copies of the goals in their own personal files, which were reviewed fortnightly. However, the service users did not receive education on the SMART concept.
Aims of this study
This study aimed to explore the perception and experience of goal setting theory and practice with service users in an inpatient neurorehabilitation setting.
Ethical approval was obtained from the Local NHS Research Ethics Committee and the Brunel University Research Ethics Committee, where the study was registered as part of an MSc in Neurorehabilitation.
Written participant information sheets were provided by the first author, with additional questions answered, prior to obtaining consent. The interview topic guide was piloted prior to the study to ensure its trustworthiness and ease of use.
All service users on the rehabilitation unit were assessed for inclusion into the study over a 2-month period. The primary inclusion criterion was that the multidisciplinary team felt that the service user was able to maintain attention and conversation for the length of the interview. The exclusion criteria included those service users deemed by the multidisciplinary team as having a cognitive or communication impairment that would prevent active participation in the interview process. Service users who were receiving occupational therapy from the researcher would also be excluded, thus guarding against the Hawthorne effect (Polgar and Thomas 2007).
The semi-structured interviews lasted between 40 and 60 minutes. The interview topic guide was a series of broad topics with additional, flexible probes to enable participants to elaborate on particular subjects (see Table 1).
Interviews between the first author and the participants were audiotaped and transcribed verbatim. The participants were given the opportunity to read the transcript to clarify whether it represented their opinion. This process of member checking was employed to enhance the transparency and trustworthiness of the data (Mays and Pope 2000). In addition, the researcher used a reflective tool (Whyte's Directiveness Scale, Whyte 1982) after each interview to monitor and reflect upon her performance.
Qualitative research is concerned with understanding the experiences and perspectives of the participants (Polgar and Thomas 2007) and, therefore, it was the appropriate methodology for this study. Thematic analysis was used to capture the meanings within the data (Braun and Clarke 2006) in relation to the SMART concept.
Each transcript was read in its entirety, with emerging individual themes relating to the SMART concept noted in the margins. This form of deductive analysis was deemed appropriate because the study sought to identify important areas of goal setting, with participants who were not formally educated on the SMART framework used within the setting. All the individual themes from the six transcripts were then collated and overall emerging themes were identified.
The qualitative data analysis software package Atlas Ti (Barry 1998) was used to aid storage and retrieval of the data, based on its functionality, cost and performance on simple data sets.
Findings and discussion
Participants' characteristics: Six people consented to participate, four males and two females, aged 28-62 years. They had all been admitted because of a single incident neurological event, including cerebral haemorrhage, contusions due to trauma and Guillain-Barre syndrome. The time since onset to participation in the study ranged between 3 and 12 months. Two overarching themes emerged from the data: the concepts in goal theory and the factors that help goal practice.
Concepts in goal theory
The operational definition for concepts in goal theory, as determined by the first author, was 'the components of goal setting that were deemed most useful by the service users'. Achievable and realistic goals
The participants identified that the components of the SMART concept that they found most useful were 'A' (achievable) and 'R' (realistic). However, it was unclear whether they thought that these definitions were different or the same.
Emotions, both positive and negative, around achieving goals was a common theme, although the participants felt that it was the team's role to ensure that goals were realistic.
In relation to the importance of realistic goals, participant 4 stated:
This finding resonates with the literature, because the importance of the goal and the belief that it is realistic are seen as two major factors that contribute to goal commitment (Locke and Latham 2002).
The participants in this study identified the 'realistic' component within SMART as essential, yet it was not explicit in the framework advocated by Bovend'Eerdt et al (2009); rather, it was an underlying assumption. However, the findings from this study suggested that the participants valued the explicit use of the 'achievable' concept to help them to manage their expectations.
The other aspects of SMART goal setting, that is specific, measurable and timely, were not deemed as important by the participants, therefore, because these concepts were not raised.
Although valuing the realistic nature of goals, the participants felt that it was the therapist's role to ensure realism, because the therapist was the person with the expertise and knowledge within the particular setting:
Therefore, realism within the goal setting process requires collaboration, as advocated by Young et al (2008), as a method for enhancing and managing expectations. Playford et al (2009) identified that goals can be used to educate but also to aid in cementing the therapeutic relationship through high levels of collaboration.
The participants in this study suggested that particular collaborative efforts should be focused on the 'achievable' and 'realistic' components. In contrast, the study by Bovend'Eerdt et al (2009) assumed the achievable concept at an implicit level. This could pose a challenge to the collaborative nature of the goal setting process. However, in practice a key component to collaborative working is a shared understanding of the concepts and language used rather than favouring a particular framework.
Long-term and short-term goals
A number of participants found that it was challenging to think about long-term goals. They suggested that long-term goals were 'scary' because there was uncertainty as to whether they were achievable; short-term goals were perceived as more helpful:
This could suggest that the participants did not link short-term goals to specific long-term goals and, therefore, there was a potential need for education on how these relate to each other within the rehabilitation process.
Understanding the relationship between short-term and long-term goals is important. This supports the literature highlighting that long-term goals set motivation whereas achieving short-term goals helps to maintain motivation (Manderlink and Harackiewicz 1984).
Factors that help goal practice
The operational definition for concepts in factors that help goal practice, as determined by the first author, was that 'there are characteristics about the goals, the therapists and the participants themselves that facilitate goal practice'.
All the participants wanted control of the topics for goal setting, with collaboration to ensure that the topics were realistic. However, their experiences of the level of collaboration differed. Those who experienced high levels of negotiation were uniformly happy with the process, especially when goals were reinforced regularly. For example, participant 4 felt that discussion around her goals occurred on 'multiple occasions', a process advocated for enhancing understanding and ownership (Webb and Glueckauf 1994).
Not all participants, however, had positive experiences of goal practice and this was linked to reduced participation in the process, an issue that has been well documented (Parry 2004):
It is essential that service users are involved in the goal setting process, although Levack (2009) reminded us that clinicians are compelled to make the best choices for service users. However, clinicians face additional challenges when deeming what is achievable, given the service specification and financial constraints (Levack 2009). This suggests, therefore, that there is a need for education with service users on what is realistic with the resources within a particular service.
The specific reasons that the participants had differing perspectives on collaboration within the goal setting process were not investigated in this preliminary study. However, there are a number of factors that could be considered.
The transtheoretical model (Diclemente and Prochaska 1998) suggests that people need to be ready to participate in rehabilitation. Levels of engagement in the goal setting process could be influenced by their adjustment to their new life circumstances; their mood, specifically whether they are anxious or depressed (McGrath and Adams 1999); their previous experiences of goal setting; and their knowledge of the process.
Although the inclusion criteria stated that patients had to have the ability to attend for the interview, there was a range in the participants' cognitive ability. Those with intact cognitive processes reported higher levels of engagement. The participants themselves highlighted that it could be more challenging for clinicians to set goals with people with cognitive impairments, a topic beyond the parameters of this study although one that warrants further investigation.
Another issue may lie with the experience and skills of the clinicians. Parry (2004) alluded that goal setting is a skilled intervention, which requires time to complete. Time pressures on staff could result in service users feeling dissatisfied with the level of collaboration and the clinical experience of individual therapists could also have an impact on the collaborative process.
Five of the six participants felt that the short-term goals needed to relate to functional tasks; for example, to manage their finances or ease carer burden. However, one participant saw functional goals as superficial and preferred impairment-based and gym-based measures. Therefore, although the literature recommends that goals should be functional (Randall and McEwen 2000), it must be considered whether this is of value to each individual service user.
The debate may not, however, be about functional versus impairment-based goals. Locke and Latham (2002) acknowledged that if participants, in collaboration, shared the clinical reasoning process, the same level of goal commitment could be achieved. Therefore, the functional or impairment-based nature of the goals may not be as important as the clinical reasoning behind them.
Feedback from the multidisciplinary team was also seen as key and this correlates with the evidence supporting the 'power' of goal setting and feedback in combination (Neubert 1998):
The message for clinicians is the need to structure sessions around specific goals and to give regular feedback within sessions on goal progression. Therefore, it is interesting to note that in the paper by Playford et al (2009), the issue of using feedback in relation to goal setting versus goal setting alone was not identified as a key issue for research.
The importance of challenge is identified in the literature (Locke and Latham 1990) and also by all participants, in relation to wanting to work hard in rehabilitation and feel challenged:
Three participants felt that it was the role of the multidisciplinary team to ensure that the goals were set at a challenging level, which is interrelated to the concept of ensuring realism. It is also recommended that, in order to maintain momentum within the rehabilitation process, new goals should be set regularly to ensure that the individual is challenged (Locke and Latham 1990).
The issue of setting challenging goals, which may lead to failure, was discussed by McGrath and Adams (1999), who identified that self-efficacy could be influenced by achieving or not achieving goals. Clinicians need to be aware of service users' self-efficacy and should modify the agreed goals to ensure the maintenance of motivation.
As ever with goal setting, the issues are never one-dimensional. Therefore, the challenges for the clinicians are to ensure that the goals seem achievable, are realistic to the service user and can act as a vehicle to aid education and enhance clinical collaboration.
Limitations of the study
On reflection, a more experienced interviewer may have gained greater depth of information. Furthermore, although efforts were made to reduce the possibility of the Hawthorne effect, it may have still had an impact on the study; the researcher was a senior member of staff, albeit not the participants' allocated occupational therapist, and responsible for clinical supervision of the occupational therapy team.
The use of an independent source to analyse the transcripts would have ensured that the themes identified were not forced upon the data, thus strengthening the methodology. However, steps were taken to minimise these limitations, including the use of a reflective diary and supervisory support from the university.
Further areas of research
Repetition of this study in other rehabilitation centres or community-based settings could aid in gaining a broader understanding from service users. Revising the exclusion criteria to include those with cognitive and communication difficulties, who make up a significant portion of patients receiving inpatient neurorehabilitation, may highlight the need to develop new practical ways of working when goal setting with this population.
Major themes of collaboration and the importance of goals being realistic support the existing evidence base. The participants' opinions on short-term goals aiding momentum and motivation also concurred with the evidence (Manderlink and Harackiewicz 1984).
Although the participants valued goals that were achievable and realistic, they also wanted them to be challenging. Playford et al (2009) suggested that the 'A' component within SMART should stand for 'ambitious' (that is, challenging) while maintaining realism. Therefore, the views of the participants in this study could be seen to support the suggestion of Playford et al (2009).
The importance of setting goals that are patient centred has been well documented (Playford et al 2009). The process empowers individuals, improves participation in rehabilitation and brings the multidisciplinary team together in a shared purpose. The participants in this study reinforced the value of the collaborative component within the goal setting process.
Our thanks to all the participants and the staff on the inpatient neurological rehabilitation unit and to the anonymous BJOT article reviewers for their insightful comments.
Conflict of interest: None.
* Service users value realistic and collaborative goal setting.
* Service users want goals that will challenge them.
* Service users want education on the goal setting process.
What the study has added
This study has added the voice of service users to the complex process of goal setting. It has highlighted the importance of ensuring that goals are collaborative, realistic and ambitious.
Submitted: 7 February 2009.
Accepted: 23 April 2010.
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Tess Baird, (1) Stephanie Tempest (2) and Alyson Warland (2)
(1) Mile End Hospital, London.
(2) Brunel University, Uxbridge, Middlesex. Corresponding author: Tess Baird, Clinical Specialist Occupational Therapist--Stroke, Tower Hamlets Community Health Services, Mile End Hospital, 275 Bancroft Road, London E1 4DF. Email: firstname.lastname@example.org
Reference: Baird T, Tempest S, Warland A (2010) Service users' perceptions and experiences of goal setting theory and practice in an inpatient neurorehabilitation unit. British Journal of Occupational Therapy, 73(8), 373-378.
... it puts into perspective what can and what can't be done while I'm here.
... it is important that you are coached or talked to about whether the goals are realistic (participant 2).
You have got to have long-term goals but it is more practical to have short-term goals so that mentally you can see you are achieving something (participant 3).
... it was the therapist who came up with that one (participant 5). I think that more communication [about my goals] was needed from both ways (participant 2).
They say you're great there, this may need a bit of work and it helps you to realise what your limitations are and what you need to concentrate on (participant 4).
The best goals are the ones that are the hardest to achieve (participant 2).
Table 1. Examples from the interview topic guide Examples of questions Examples of probes * Was the goal setting process * Interesting, can you go explained to you? into more detail about that last point? * What are the important components in setting a goal? * Can you elaborate on that? * What do you understand by the term * How important is that? SMART goals'? * Do you think you could set your own rehabilitation goals? * Should goals be set around enhancing the practical components of your life? That is, should they be functional in nature? * What factors make goal setting difficult? * Who set your rehabilitation goals? * How were your goals agreed? * What is the multidisciplinary team's role in goal setting? * How much input should the multidisciplinary team have in setting rehabilitation goals?
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