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Neuro rehab therapies

Goal setting revisited



Goal setting is always a hot topic in neurorehabilitation – it has, in many ways, become much more than the sum of its parts and, as a concept, it is saturated with literature.

There is frequently new research evaluating components of goal setting or describing emerging ideas in the field, and this can be difficult to navigate, even with all the time in the world.

As clinicians, however, there is rarely ever any spare time at all. If we listen to what we are told about how important goal setting is for our service users and teams, we need to know exactly what it is, why it matters, and how we can do a good job of it.

Goal setting, simply, is concerned with figuring out what we would like to accomplish. This is apparent in so many factions of our daily lives, from thinking about our career aims to writing our day’s to-do list.

If we don’t know what we want to work towards, we might go from job to job in life with no real direction, or we might get to the end of a day and realise that we haven’t really accomplished anything.

Setting goals keep us focused on what is meaningful to us and allow us to make short-term plans towards achieving it.

This is no different in neurorehabilitation. When someone has a brain injury, they might so often feel that they just want to get “better” and for life to get “back to normal”.

What does that really mean? How do we quantify “better” and “normal” and, more importantly, what plans can we make to work towards that? Instead, it is more useful to speak with a patient about, “What specific differences to the current situation would improve your life and wellbeing?”

In this instance, a patient’s definition of “better” might really mean “I want to be able live independently again”.

This is a much clearer aim and, as such, can be set as a goal for the patient’s rehabilitation.

An interesting part of this discussion is reference to “the current situation”, referring to the extent to which someone is able to function in daily life and participate in essential and meaningful activities.

How do we quantify this? Goal setting literature suggests that this should be based in a functional assessment of which there are many different types, such as the International Classification of Functioning, Disability & Health (ICF).

They are designed to consider each aspect of individual and rate their level of impairment in those areas, using standardised assessments, patient report and observations from family members.

The results of such an assessment can then offer a comprehensive understanding of what might be the most meaningful areas of a person’s functioning to address during the goal setting process.

Once the foundations of a goal have been set, we can then start to think about how to measure progress in that goal.

Our first instinct is possibly marking a goal a either “achieved” or “not achieved” similar to crossing a task off a to-do list – it is quick and satisfying.

However not all goals, especially those in neurorehabilitation, are so black and white, and instead we need to look at the grey.

To do this, we can measure goal achievement using Goal Attainment Scaling (GAS) which centres around a set of scaling stages to record the possible outcome of a goal, following this framework:

+2                    Considerably more than achieved

+1                    Slightly more than achieved

0                      Goal situation

1                      Slightly less than achieved

2                      Slightly more than achieved

Using this scale, a single goal can be rated in its success on a spectrum rather than a “yes” or “no” approach, affording patients greater chance of success but also better mapping a patient’s journey within their rehabilitation.

After setting a goal and defining its stages, you are left with an aim for the future. There is something on the horizon that everyone is heading towards: the patient, their family and their team.

Next we need to think about how we get there. This is where everyone around a patient thinks about the steps that they will individually take towards getting a patient to that goal.

For example, if a patient has a goal to be able to walk without support from a family member, their physiotherapist might set themselves an objective of working with the patient on developing the ability to use a walking frame, while an occupational therapist might set their objective as modifying the family home to install supports to aid the patient’s mobility. Everybody defines their “to-do list” for that goal.

These processes are many and complex to complete manually. This was only too apparent within our paediatric neurorehabilitation service, Clinical Neuropsychology Services Ltd.

Whilst working towards our target of improving goal setting within the service and clients’ teams, it became clear that there was so much to understand and so little time within a normal working week of client appointments, meetings and the rest to do it all by hand.

As a result, with the help of a patient software developer, Goal Manager was developed to streamline all of the important goal setting components into one process.

It facilitates the completion of a functional assessment whose results form the foundations of goals measured through GAS, before allowing interdisciplinary professionals to log on from wherever they are to update their individual objectives for each goal.

Goal Manager was originally developed to improve our service however was soon requested by our colleagues and has subsequently grown into a much larger project.

As a result, we have learned a great deal about goal setting along the way.

Over a series of articles, we aim to present what we have discovered in a way that hopefully makes meaningful and effective goal setting more accessible to all.

We will be covering the details of functional assessments, GAS, SMART objectives and more, including stories from those who have seen the benefit of it.

Merryn Dowson is an assistant psychologist at Clinical Neuropsychology Services Ltd., the rehabilitation provider which pioneered the goal-setting app Goal Manager. For more information about the platform visit www.goalmanager.co.uk. This article was written with supervision from Dr Penny Trayner, paediatric clinical neuropsychologist.

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