Almost all patients and families involved with rehabilitation will, sooner or later, have a discussion about goals with a therapist, doctor, nurse or other team member. Sometimes this discussion is one sided – “Our goal for you is to …“; sometimes it appears equally one-sided the other way – “What are your goals? ….. No, it is up to you, not me.” Ideally all decision-making, including that about goals, should be a shared process.
In this page I will discuss five aspects of goals and goal setting, listed below. You can jump straight to the one you want by clicking in the red word:
- Words used; many words have special or particular meanings, explained here.
- Relevance of goals; the reasons for setting goals are explained here.
- Benefits of setting goals; these are discussed here.
- Your role; what you can do the help yourself and the team, discussed here.
Words used.
Rehabilitation is full of jargon – “special words or expressions used by a profession or group that are difficult for others to understand” (Oxford English Dictionary) – and although you may think you understand the words used by professionals, they often have hidden implications when used by professionals working in rehabilitation. You and the therapist have different understandings of the word. Indeed, different people within a team may also have different understandings of words. So, here goes ..
Goals. When used in rehabilitation, it refers to something to be achieved over a period of time. The nature of that thing, and the length of time are defined during the process of setting a goal. A goal can be anything from “standing without falling and without support for one minute, to be achieved in four days” to “return to live at home with your daughter, looking after her children while she works, in one years’s time” The important point is that it refers to a future state that is different from now.
Goal attainment scaling, commonly referred to as GAS. This is a basically way of saying that someone did better than expected, much as expected, or less well than expected. It involves attaching numbers to the words to calculate a score. Sometimes, in addition, the patient may be asked how important they think the goal is (anything from very to not at all), and they may even be asked how difficult they think it will be to achieve, with a similar range of possible answers. It can be a useful way to set goals; its value as a measure is uncertain; and there are risks of invalid interpretation and use of data. If you want to read a more in-depth critical review of this approach, click here.
Aim, or long-term goal. In some rehabilitation services goals will be split into long-term goals, with one of several words used being aims, and a larger number of shorter-term goals. There are good reasons for this classification. Unfortunately, there is little consistency about what is considered ‘long-term’ – anything from months to many years. Second, some people consider that aims must be goals concerned with social functioning, and that goals for activities such as walking cannot be aims. So, when you hear the word, ask what the speaker means.
Objective, or medium-term goals. In services that do differentiate goals, the mid-term ones are often termed objectives.
Targets, or short-term goals. If this term is used, it usually refers to very specific actions such as “making a application to the housing department by next Tuesday” or “doing a home visit within a week.“
Life-goals. In some services, the team pays attention to what is important to the patient personally, not in terms of specific activities, but in terms of values, and what makes life worth living. There is no single word for this. It incorporates such ideas as the meaning of life to the person, what they think their purpose in life is, what type of person the feel they are, and so on. They are a difficult concept to describe, and life goals are difficult to discuss with other people.
For one patient who was having to go to a nursing home, we discovered that the only thing that he really valued in his life was his dog. We found a nursing home that let him have his dog with him.
More generally, when asked what really makes life worth living, most people refer to social relationships and one or two all-consuming interests – which vary greatly.
Goal-setting (or goal-planning) meeting. Meetings to discuss goals have a huge variety of names – case conference, family meeting, review meeting, rehabilitation planning meeting etc.. The extent to which the meeting allows a discussion, where change is allowed, varies. Not uncommonly, the meeting is primarily an opportunity for each team member to inform others about what they are going to do. Sometimes patients and families attend. Very occasionally the patient may chair and lead the meeting.
‘SMART’ goals.
A phrase you will hear sooner or later, often used between team members, less commonly used with the patient, is that goals “.. must be SMART“. SMART is an acronym for five words describing how goals should be set. Unfortunately there is no agreement on what the five words are! (see here for more information) For example ‘A’ originally stood for Attributable (i.e. who was responsible for doing the work), and is now usually used for Achievable (by the patient) but sometimes stands for Ambitious, or Agreed, or Appropriate, or ….
You can see that there are many words used. You can see that the meaning can be quite vague, and may vary even among people working in the same team. There you should always ask the user to explain exactly what they mean by whatever word or phrase is used. Do not be surprised if two team members use word differently.
Why are goals important?
Goal setting has become embedded in rehabilitation. Commissioning contracts often specify that all patients should have rehabilitation goals. Teams usually ask and talk about goals. Books are written about goal setting in rehabilitation, for example this one. Why is the setting of goals considered so important?
Any reader who works in a business will be familiar with goals, and the practice of setting goals systematically probably started in business. Most of the early research was conducted in business organisations. My own introduction to goal setting was through an assistant psychologist, Alison Davis, whose father worked in a business and told her about it. This contact led to the first of many publications.
Research has shown, reasonably conclusively, that giving someone (including yourself) a goal to work towards improves performance of the activity concerned. You probably set goals, or have done so, for things like losing weight, learning a new skill, playing competitive games, finishing a do-it-yourself activity etc. Most evidence comes from studies in organisational management and sports. The evidence in rehabilitation research that patients with goals achieve a better outcome in their rehabilitation is not very strong, but there is no evidence that it is harmful.
Even if the goals themselves do not motivate patients sufficiently to alter outcome, the fact of having goals set may well improve rehabilitation.
For example, the fact that the therapist has suggested a goal makes concrete what is anticipated. Rather than “you will get quite a bit better“, the patient is told “I think we should set a goal of walking 10 metres on your own in four weeks’ time.” This may be more or less than the patient expected, or faster or slower, but it is much more concrete. Many patients appreciate the specificity, as it reduces their uncertainty and anxiety. Sometimes the goals set confront a patient with the reality of their future which, although unpleasant, may allow the process of adaptation to start.
In summary, goals in themselves probably improve some outcomes, particularly if well-set, through increasing the motivation of and effort made by the patient. They also help by making explicit to everyone the likely speed and extent of change the patient can expect.
Benefits of goal setting
The previous section concentrated on setting goals to motivate patients, and to improve outcomes. It also suggested another benefit, making the future more concrete and less uncertain. This part discusses other likely (but not necessarily proven) benefits arising from the goal setting process.
Setting goals requires the professional and/or the team to think about what might be possible. Thinking often leads to discussion, to consideration of other possibilities, to consultation with the patient, to realisation that other problems may exist, and so on. In other words, considering a goal requires a person or team to formulate the situation more clearly, which might expose unconsidered problems (e.g. can a wheelchair fit through the doors in the house?) or factors that can be treated.
Goals need to be accepted and understood by the patient. Achieved concordance between the patient and the therapist may to an exploration of the patient’s interests, goals, expectations etc. The exploration may lead to changes in the goal, and may lead to exposure of other problems. The exploration undoubtedly will increase the team’s depth of understanding.
Thirdly, many goals may need the help of other team members, and other goals set by one person may limit other members in pursuing their goals. These interactions, if exposed in a meeting, will lead to the development of a better plan and rehabilitation programme. They may precipitate further exploration of the factors affecting the situation.
Last, the discussion may draw attention to the need to involve teams from other services or organisations at an earlier stage. Setting goals collaboratively should lead to more efficient collaborative working, with actions being undertaken at the best time relative to other actions.
In summary, just as setting a goal makes concrete the patient’s future, converting a generality to something specific, so setting goals win a team starts to make concrete the general principle of team work, and collaboration. Being specific also ensures that the team obtains all the relevant information needed, and identifies all the actions needed.
Your role in goal setting
Goals can only have a positive effect on the benefits offered by rehabilitation if they are of interest to the patient. Although team members might guess at what is of interest, it is much better if, as far as possible, the patient is positively engaged from the outset. This section outlines actions that the patient (and family) can take to increase the ease, relevance and benefits of goal setting.
One difficult but important action is for the patient to consider and discuss (with family, friends, team members as the person wishes) what are sometimes referred to as life goals but can be considered also as what the person thinks that their purpose in life is, or what they think the meaning of life is for them. Other ways of looking at it include thinking what they look forward to happening or doing, who they really missed during the lockdown, or what they still wish to do before they die.
Thinking about these matters helps, because when faced with a choice of where they put their effort, for example between dressing independently but with risk and taking over one hour, or being dressed and spending time chatting to friends, they will know which is more important – independence and the freedom to choose when they dress, or some loss of that freedom, but the opportunity to see people. It is easier to have thought about the broad important things rather than trying to decide ‘from scratch’ when the choice has to be made.
A second difficult area is for the patient to ensure that she is as involved in the process of deciding goals as she wishes, and in the way that she wishes. For example some patients really want to be present, in person, at the team meeting where goals are decided. Others, quite understandably, consider being at a team meeting is too stressful, and would rather discuss matters beforehand. Yet others prefer the team to make decisions and then to discuss them afterwards, with the option of changing them.
There is no ‘correct’ or ‘best’ method, and different teams have different views. Ideally someone should explain to the patient and family the local process, and the options available. They should then discus what the patient and family would like. If a patient wants little active involvement, they should document their priorities and make sure that the team (and their family if they are involved) know the priorities so that they can used them to make decisions consistent with the patient’s likely wishes.
The only choice that should be avoided is the choice not to participate at all. At a very minimum, the team should always explain to a patient what the goals are, and how they were decided upon. The patient should always be given (and ask for) a copy of any documents produced.
In summary, the patient needs to consider how he or she is going to choose between options, when they arise; they need to identify three or four factors that represent their priorities in life. The patient also needs to discuss with the team, sooner rather than later, how much they wish to be involved in identifying and setting goals and in what manner they want to engage.