Goal setting, teams & rehabilitation: What do we know and where should we go?

Richard Siegert, PhDProfessor of Psychology and RehabilitationSchool of Public Health and Psychosocial Studies and School of Rehabilitation and Occupational StudiesAUT University Auckland, New Zealand richard.siegert@aut.ac.nz 

Health and Rehabilitation Research Institute

5 Hallmarks of Rehabilitation

ICF Inter-professional team Goal setting Measurement of outcomes Person in Context

Road Map

What do we know about goal setting in rehabilitation?

Four important questions: Why do we use goal-setting? Does it work? What does everyone agree/disagree on? How does it really work in practice?

Team function and continence management in stroke rehabilitation How do team characteristics relate to rehabilitation outcomes?

Where do we go from here?

Goal-setting in rehabilitation

Widespread agreement among authorities on clinical rehabilitation that setting goals for, or with, a patient is an essential component of rehabilitation.

It might even be considered part of ‘best practice’ in rehabilitation

Barnes & Ward (2000) Textbook of Rehabilitation Medicine, Oxford University Press p.8

“the essence of rehabilitation is goal-setting…..if rehabilitation is to be taken forward, agreed goals and outcomes are essential”

Wade, DT (1999) Clinical Rehabilitation, Editorial, p. 273.

“….the identification and setting of appropriate goals is one of the skills that most specifically characterizes professionals involved in rehabilitation.”

Siegert & Taylor (2004) Disability and Rehabilitation, 26, pp.1-8.

“…goals and goal setting are a fundamental component of any sound rehabilitation programme.”

So perhaps we should just get on with it and….

But is it really that simple…

Patients not actively involved Goals primarily about mobility,

physical independence…‘patient does not participate in

the goal-setting process’

Wressle et al. (1999) The rehabilitation process for the geriatric stroke patient-an exploratory study of goal setting and interventions. Disability & Rehabilitation, 21(2), p.86.

Wade, DT (1999) Clinical Rehabilitation, Editorial, p. 273.

No accepted or consistent goal-setting vocabulary e.g. no definition of ‘goal’.

Have things improved since then? 1998 ….. 2009

‘There is little or no evidence to guide clinicians on the most appropriate method to undertake goal planning…’ (1998)

‘Setting goals with the patients and monitoring their achievement is a core practise within much rehabilitation, but the evidence base behind this practice is patchy.’ (2009)

Four Important Questions

1. Why do we use goal-setting?2. Does it work? 3. What are our shared beliefs about goal-

setting?4. What do we know about goal-setting in

rehabilitation teams?

Why do we use goal-setting?

Systematic Review MEDLINE, EMBASE, PsychINFO, CINAHL 1966 – October 2004 ‘Goals’, ‘goal attainment’, ‘goal

setting’,’rehabilitation’, etc 1364 abstracts screened 530 abstracts categorised by purpose of goal

planning 123 papers read in full Thematic analysis

Levack, Dean, Siegert & McPherson (2006), Disability and Rehabilitation, 28(12), 741-749.

Purposes of Goal Planning in Rehabilitation:

Improving outcomes Enhancing patient/client autonomy Evaluating outcomes Contractual, legislative or

professional requirements

To improve patient outcomes – 4 Mechanisms

By influencing conscious motivation By enhancing specificity of training By secondary therapeutic effects

such as increased self-awareness By improving clinical teamwork

Does it work? What is the evidence underpinning goal-setting in rehabilitation?

Systematic review 9 databases 1052 citations – 975 excluded 93 studies – 71 excluded 19 articles included RCT + adults + post-acute or chronic

condition + GS independent variable Rated on PEDro scale

Levack, Taylor, Siegert & Dean (2006), Clinical Rehabilitation, 20, 739-755.

What is the evidence underpinning goal-setting in rehabilitation?

We found limited evidence that goal planning can influence patient adherence to treatment regimes.

We found strong evidence that prescribed, specific, challenging goals can improve immediate patient performance in some specific clinical contexts

But evidence that these translated in to longer term outcomes inconsistent

Cochrane Review

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009727/abstract

What do health professionals believe about goal-setting?

What do we agree on? Consensus view 24 UK rehabilitation ‘goal-setters’:

Goal-setting is a core component of rehabilitation

That goals should be specific, relevant, stepwise and time-limited.

Consensus that goal-setting has an impact on the patient-professional relationship

That professional expertise and time are key ingredients for success.

What do we not agree on?

There was no consensus about how to measure goal-achievement

Whether goals should be achievable or challenging.

Patient-centred goal-setting was considered desirable but not always achievable due to conflicting interests.

Goal attainment scaling (GAS)

Playford, E. D., Siegert, R. J., Levack, W. M. M., & Freeman, J. (2009). Areas of Consensus and Controversy about Goal-setting in Rehabilitation: A Conference Report. Clinical Rehabilitation.

What do we know about goal-setting in rehabilitation teams?

Limited robust evidence on goal-setting and teams in rehabilitation

Numerous descriptive studies e.g. Bloom et al. studied concordance

between MS patients’ goals and their team’s goals for them

Concluded patients and teams do not always agree on goals and patients often have higher expectations

Barnard, Cruice & Playford (2010) Strategies used in the pursuit of achievability during goal setting in rehabilitation. Qualitative Health Research, 20(2), 239-250.

Conversation analysis of 6 goal-setting meetings patient/team inpatient neuro

3MS, 2SCI, 1 stroke patient ‘the treating team shaped the meetings’ Teams actively intervened to ensure goals

were ‘achievable’ and met quality criteria for goal-setting

Goal setting - is it really that simple in practice?

Levack, Dean, Siegert & McPherson (2011) Navigating the borderlands of patient-centered

goal-setting Grounded theory approach 2 inpatient units in NZ 9 stroke survivors, 7 family, 28 health

professionals

Certain goals privileged over others:

Short timeframes Conservative or ‘realistic’ outcomes Physical functioning 45 IDT goals 38 related to physical functioning Remaining 7 were tasks for clinicians 35 goals within 1-2 weeks

Ruby 90 yrs – initial keyworker meeting

Ruby: And then another, what I’m going to do is….I can, I can call this a goal…it’d be accurate…but what I thought I’d like to be in a position to do was get on the Internet

Nurse: Oh, interesting, you’ve got a computer at home? Ruby: No, I haven’t. That’s the point Nurse: Oh, okay Ruby: They’re expensive Nurse: Yeah, they are expensive Ruby: yeah, so…

Levack, Dean, Siegert & McPherson (in press) Navigating the borderlands of patient-centered goal-setting. Patient Education and Counseling (under revision)

Goal setting promoted as a way of enhancing patient-centred rehabilitation in inpatient stroke rehabilitation.

However, health professionals control the of content of discussion with patients about goal setting, restricting or limiting this discussion to content that fits the sorts of goals that have already been privileged by the inpatient rehabilitation system.

Levack, Dean, Siegert & McPherson (in press) Navigating the borderlands of patient-centered goal-setting. Patient Education and Counseling

What appears to happen is the direction of rehabilitation and prioritisation of interventions is decided on by the health professionals first, with goals then set to reflect these decisions

Undermining the notion of patient-centred goal setting, even when patients have been involved in the goal setting process and undermining the belief that goals provide direction for rehabilitation

Predicting stroke outcomes

Falconer, Naughton, Dunlop, Roth, Straser, Sinacore et al. APMR, (1994)

Classification tree approach to predict favourable outcomes of 225 stroke inpatients

Favourable discharge Discharge to community Survival till 3 months Minimal support for ADLs

Which variables were best predictors of outcome?

The classification tree correctly predicted 88% of the sample using only 4 of the predictor variables:

Financial resources

Independence ▪ Toilet management▪ Bladder management ▪ Toilet transfers

What do we know about team function in rehabilitation?

Strasser D et al. Prospective observational study of 46 VA

teams, 530 professionals, 1688 stroke survivors 10 scales:

team relations team actions

Predicted outcomes controlling for case mix FIM discharge destination LOS

Six Dimensions of Team Functioning:

Organisation/order Task orientation Innovation Inter-professional relations Managerial practices - communication,

‘teamness’, effectiveness, utility of quality) information

Leadership

What do we know about team function in (stroke) rehabilitation?

Functional improvement predicted by: Highly organised teams Employed good quality outcome data in

therapy process Less emphasis on concrete, practical tasks

High levels of managerial effectiveness predicted longer LoS

No team variable predicted discharge destination

Team functioning and continence management in stroke rehabilitation

Strasser et al. (2005) Examined whether team functioning

predicted continence management in stroke inpatient rehabilitation

Surveyed 530 team members, six disciplines, 46 teams, 1688 patients

Which dimensions of team functioning predict continence?

“Higher functioning rehabilitation teams predicted the likelihood of a stroke patient demonstrating increased urinary continence at discharge

Continence: Team relations (order & organisation) Team actions (utilising quality information)

Summary: Goal setting

There is (limited) evidence to support the use of goal setting in rehabilitation but the evidence base is growing

We need stronger evidence that goal setting:

improves team performance improves patient outcomes improves client-centredness

We need evidence as to the best way(s) to do goal setting

Summary: Teams

Organised, structured teams that collect and use quality information on patient progress get better patient outcomes

This is true for continence specifically and for rehabilitation outcomes generally

We know very little about how goal setting and team characteristics interact to influence outcomes

I would like to acknowledge and thank the following people:

My goal-setting research collaborators and colleagues:

Sarah Dean Jean Hay-Smith William Levack Kathryn McPherson Diane Playford Will Taylor Mark Weatherall

richard.siegert@aut.ac.nz 

References:

Barnard, Cruice & Playford (2010) Strategies used in the pursuit of achievability during goal setting in rehabilitation. Qualitative Health Research, 20(2), 239-250.

Kleingold, A., van Mierlo, H., & Arends, L. (2011). The efect of goal setting on group performance: A meta-analysis. Journal of Applied Psychology, 96, (6), 1289-1304.

Kneebone, I. I., Hurn, J.S., Raisbeck, E., Cropley M., Hiro Khoshnaw, H., & Milton, J. E. (2010). The validity of goal achievement as an outcome measure in physical rehabilitation day hospitals for older people. International Journal of Disability, Development and Education, 57 (2), 145-153.

Levack, W. M. M., Dean, S. G., Siegert, R.J., & McPherson, K. M. (2006). Purposes for goal planning in rehabilitation: The need for a critical distinction. Disability & Rehabilitation, 28 (120), 741-749.

Levack, W. M. M., Dean, S. G., Siegert, R.J., & McPherson, K. M. (2011). Navigating patient-centred goal setting in inpatient stroke rehabilitation: How clinicians control the process to meet perceived professional responsibilities. Patient Education and Counseling, 85, 206-213.

Levack W, Taylor K, Siegert RJ, & Dean S. (2006), Is goal planning in rehabilitation effective? A systematic review Clinical Rehabilitation, 20, 739-755.

Playford, E. D., Siegert, R. J., Levack, W. M. M., & Freeman, J. (2009). Areas of Consensus and Controversy about Goal-setting in Rehabilitation: A Conference Report. Clinical Rehabilitation.

Strasser DC et al. (2005). Team functioning and patient outcomes instroke rehabilitation. Archives of Physical Medicine and Rehabilitation, 86, 403 – 409.

THE END

richard.siegert@aut.ac.nz