Goals and hope in rehabilitation
Most people start rehabilitation with great hope. However, they often lose hope when they are involved in goal setting. Goals and hope are needed and should complement each other to increase beneficial change. This page is primarily interested in goal setting, looking at it from a patient’s perspective, but it also considers the involvement and contribution of families. Few patients have encountered goal setting in other healthcare services, and most patients wonder why rehabilitation is so interested in goals. Any patients who are involved in management or high-level sports will be more familiar with goal setting. It is a well-researched method of motivation for achieving better outcomes. William Levack and colleagues reviewed the purposes and mechanisms of goal planning in rehabilitation. They found four primary purposes: to improve the person’s outcome, to increase the person’s control over rehabilitation, to measure improvement, and to satisfy external requirements because many funding or quality monitoring organisations require goals to be set. In part five, goals and hope, I conclude that hope has an important role in goal-setting; this is covered in detail in a post on hope in rehabilitation.
Table of Contents
Introduction
Hope and goals concern the future. A goal is “the object of a person’s ambition or effort; an aim or desired result”. [Oxford English Dictionary. (OED)] It is the journey’s end – which implies that the person is on a journey, passing through various places en route and knowing where they wish to reach. Hope is similar, “a feeling of expectation and desire for a particular thing to happen.” [OED}
The difference between hope and goals concerns distinguishing between “I would like to happen” and “I will strive to achieve.” Hope is a desire or expectation, whereas a goal implies the person must be active. Goals in rehabilitation also tend to be concrete, as will be discussed, whereas hope is typically vague or general. For example, I might hope to meet you at the next conference, whereas I might set a goal to meet you at 09.30 in the registration hall at the conference entrance.
Disappointment arises in rehabilitation when the person’s general hope to get better is challenged by being offered a specific target that is not near their expectations without further explanation.
Before considering how to avoid this, I will explain some aspects of goal setting, starting with the words used and the rehabilitation jargon.
Rehabilitation jargon around goals.
Like all healthcare, rehabilitation is full of jargon, “special words or expressions used by a profession or group that are difficult for others to understand.” {OED} Commonly used jargon includes upper limb (the arm), ambulation (walking), and cognitive skills (referring to memory, concentration, problem-solving, etc). I will only consider those typically used by rehabilitation staff concerning goals.
Goals
A goal is a state to be achieved by a specific time. For example, the future state may be a person’s ability to walk 10 metres without support in less than 20 seconds. However, a goal may also be to undertake a visit to a person’s home before a date, to obtain and try a new wheelchair, or to make a referral to a special clinic for advice on a hearing aid. As discussed later, goals should be specific if possible, but this is not always appropriate or achievable; for example, to be less depressed is essential but challenging to measure.
There are several types of goals, which are considered below. Goals may also be used to measure change, which is called goal attainment scaling.
Goal attainment scaling (GAS).
When a goal is specified with a time limit, it is possible to measure whether it is achieved within the time frame. Thus, the goal was exceeded (quicker or more significant change than expected), was completed, or still needs to be achieved. This gives a measure (for example, +1, 0, -1). It can sometimes be greatly exceeded or failed, given a score between -2 and +2. Two further refinements are possible. The person can say how important it is to them, and the therapist can tell how difficult it is.
I have reviewed many reasons why this is an invalid way to measure achievement. Despite this, the process is still used as a measure. Using goal attainment scaling is one technique for facilitating discussions between therapists and patients, especially around importance to the patient and likely difficulty.
Aims, objectives, targets (and similar words)
Goals should be set in collaboration with an overall, holistic plan. To be most effective, the process of setting goals requires the identification of a few high-level goals set in the distant future. These link back to medium-term goals set soon, which relate to short-term, immediate goals.
Different words for the goals identify these various levels and timeframes. High-level goals may be referred to as aims, aspirations, life goals, and many other words. They are usually concerned with social roles, but the nature of these will be discussed later. Medium-term goals may be called objectives or intermediate goals, and short-term goals may be called targets.
Unsurprisingly, the terms used vary greatly. The critical point is the difference in timeframe and level; rehabilitation teams should clarify this when using their jargon
Life goals.
Sometimes, a person’s high-level goals are called life goals. A quite readable academic review considered “Life goals: the concept and its relevance to rehabilitation.” Life goals are only one example of high-level goals. I will discuss the issue of the overarching, top-level, long-term goals later.
ADL (Activities of Daily Living)
When discussing goals, teams often refer to activities of daily living, a term introduced by Sidney Katz in the 1950s. The term, abbreviated to ADL, mainly relates to activities or functions required to live independently of daily support. The activities are basic, physical, or personal (BADL or PADL). They encompass washing, dressing, toileting, continence, and indoor mobility.
The more complex activities to achieve greater social independence, such as domestic household and community activities such as cooking and shopping, were called instrumental activities, abbreviated to IADL. A more detailed discussion is available.
Goal-planning or goal-setting (meetings)
In more complex cases, the team will generally meet with the patient to discuss goals and make a rehabilitation plan. The meeting usually also covers formulation, explaining the situation, the likely change over the next few months, and what important factors influence the plan. These may be called goal-setting or goal-planning meetings. Still, they have many other names, such as a family meeting, an MDT (multidisciplinary team) meeting, a discharge planning meeting, or a rehabilitation planning meeting.
Why set goals?
Studies in management science have demonstrated that setting people goals increases the speed and extent of their behavioural change. There is good evidence about the types of goals that are more effective. This research started in the 1960s and was soon incorporated into business management. It increases a person’s motivation and commitment to change their performance at an activity.
Goal setting entered rehabilitation significantly in the 1980s. From the outset, it was linked to measurement using goal attainment scaling to measure how well someone increased their performance. However, as I have said, goal attainment scaling is an inappropriate way to measure outcomes.
George Doran first introduced a way to write more effective goals in business. It was intended as a guide to setting goals, not a rule; he realised that many objectives are hard to specify, and he cautioned against prioritising measurement over importance. He invented the now widely used acronym that one should make goals SMART:
- Specific
- Measurable
- Assignable – specifying who will do it
- Realistic
- Time-related
There is tremendous pressure for all rehabilitation goals to be SMART. People overlook several matters. Over 110 words are now attached to the five letters. Many important goals cannot be made very specific or measurable. Third, George Doran acknowledged that many goals can only meet two or three criteria.
Goals should be set jointly by the patient and the rehabilitation team. This will improve the efficiency and effectiveness of the team’s activities. Moreover, if other parties are involved, such as family members or social services, they should be engaged because setting joint goals increases the commitment and motivation of all parties.
Therefore, a second reason to set goals is to improve team coordination and increase team members’ motivation.
Lastly, goal setting involving the patient increases the relevance of the goals and the person’s sense of control, which is the first step toward self-management.
High-level goals.
Rehabilitation services mainly concentrate on short-term measurable goals that lead to earlier hospital discharge. Moreover, despite meeting as a team, many goals are set by and only apply to a single profession. The goals are nominally set after consultation with the patient and other team members; in practice, they are often proposed by the therapist.
Even from business studies, the research evidence emphasises the value of a few overarching longer-term goals, such as completing the HS2 to Manchester on time or reducing the number of children in poverty in the UK. Short-term goals in isolation are much less effective and may lead to gaming, meeting the goals by alternative means.
Therefore, the goal-setting approach should start from a distal goal and work towards the immediate short-term targets for two reasons. First, patients will only commit if they understand how the immediate activity leads to the desired long-term outcome. Second, one may undertake irrelevant or unnecessary actions unless one starts from a long-term goal. Each person must appreciate how their activity is contributing.
Organisational mission statements, another example of a high-level aim, are only effective if accepted by the whole workforce. Thus, in rehabilitation, the long-term goals must be of interest to the patient.
Identifying a person’s high-level, long-term goals is challenging because different people prioritise different aspects of their lives. For example, some people prioritise social roles, others adhere to a religious or moral framework, and others prioritise acting to benefit society.
One approach for patients to identify and describe their aims is to use life goals, which I recently discussed on a page related to the General Theory of Rehabilitation. Alternatively, patients might prefer to think of their purpose in life: Joshua Lee and colleagues identified “Purposefulness as a critical factor in functioning, disability and health.” Patrick McKnight and Todd Kashdan have also suggested that purpose in life sustains health and well-being.
Another approach is to use Maslow’s theory of motivation, first described in 1943. I have written about his framework in a blog post on Maslow’s needs, where I outline how it offers another way to consider higher-level needs.
At this stage, the main message is that most people have some fundamental ideas used to make life choices; they will rarely have thought much about what they are. As I will now discuss, hope may help identify what is essential.
Goals and hope.
In 2006, Charles Snyder and colleagues wrote, “it is suggested that the hope construct may be helpful in fostering adaptive rehabilitation processes through the use of intervention techniques aimed at creating clearer and more sustainable goals, increasing pathways thoughts, and instilling greater agency.” They conceive of hope as a “goal-directed cognitive motivational process”.
Thus, hope is an extension of the goal-setting process. A person may have some high-level goals they wish to achieve and have considered ways of achieving them. While healthy, busy, and progressing satisfactorily, most people do not articulate their hopes explicitly. The evidence in the article by Charles Snyder and colleagues shows that hope can positively affect change and adaptation.
When someone is unwell and has limitations on what they can do (i.e. is disabled), the challenge is to match the hoped-for outcomes and proposed pathways to what is achievable. The person will often articulate their hope concretely, such as “I want to return to work by next year”. This concrete idea typically represents their less concrete priorities, previously not considered in depth, and it should be treated as an entry into discussions, not as an unrealistic aspiration.
Thus, hope enables discussion about what aspects of work make it a high priority. These could include money, enjoyable social contacts, status, a fear of boredom and loneliness, enjoyment of the activities involved, and so on. This can lead to further discussion about ways to satisfy the underlying needs.
In other words, hope is a valuable resource that must be used, not discounted. A person with a new disability that is significantly affecting their life needs to consider carefully what drives their hope. This is usually an emotionally challenging task because people rarely do that. However, the payoff is finding alternative ways of satisfying the underlying driving forces and some pathways that enable at least some satisfaction of the underlying desires.
The role of rehabilitation staff is to accept hope and facilitate the patient’s understanding of their own motivations, finding alternative, equivalent, achievable activities and a way to achieve them. This is a process of psychological adaptation (of higher-order goals) and coping, which I have discussed elsewhere.
The patient’s role.
Although most rehabilitation professionals are aware of the principles behind goal-setting, they often concentrate on short-term, professionally driven actions. This is reinforced by an imperative to make rehabilitation a brief, goal-driven activity allowing discharge from the hospital. In the community, rehabilitation’s primary interest is reducing the risk of further hospital admission; doubtless, the staff would like to do more, but contractual limitations discourage it.
Consequently, the greatest challenge facing patients and their families is having meaningful discussions with their rehabilitation team about longer-term and higher-level goals. The team will feel and often say that these issues are too complex, require other people to be involved, are outside their scope as funded, or give different reasons. It is also emotionally and intellectually challenging for them because it requires more thought and work to reach a satisfactory conclusion.
Nevertheless, the team should have the expertise to discuss and outline a plan, even if they cannot take it forward. They could suggest resources from the local rehabilitation network.
Therefore, the patient’s first role is to remind the team to be person-centred and holistic and to consider where the person will be in five years.
The second role is to spend some time also considering the broader picture and what is most important. This can be done by thinking about five years ahead. It would be best if you were open to helpful discussions about realistic goals but did not accept blunt statements rejecting your hopes without any debate.
The third role is to participate actively in goal setting, asking what the likely benefits are and how the goal links to your more significant aims. Once you have had the discussion, you may decide you are not interested in a goal, and if so, you should let the team know. For the remainder, you must work hard at practice, not only in planned sessions but wherever and whenever possible.
Conclusion
Goals are a powerful way of increasing the commitment and motivation of patients and rehabilitation team members to the rehabilitation plan. They can also significantly improve the coordination and general direction of actions, facilitating a person’s adaptation to new circumstances. The goals must be set collaboratively and linked to a person’s more abstract, long-term aims to succeed. The context of most rehabilitation militates against success because the team is under tremendous pressure to focus on the short-term and only to set measurable goals. The patient’s position is weak, and they lack autonomy through lacking knowledge or understanding. Furthermore, their hopes may be discounted as unrealistic rather than as an opportunity to explore alternative aims and pathways. The patient should expect an outline longer-term plan while recognising that the team may be unable to undertake it. More appropriately used goals may lead to a better outcome.
