Transcript Slide 1

Conceptualising rehabilitation goals
and making them SMARTER
Deborah Hersh, PhD
Senior Lecturer
Speech Pathology, SPSS,
ECU
Contact Info: www.ecu.edu.au/research/week
It is important to set goals...
Contact Info: www.ecu.edu.au/research/week
Setting a Goal
• essential part of rehabilitation
– Wade, 1998
• a fundamental component of
contemporary rehabilitation practice
– Levack et al., 2006
• integral to person-centredness
– Cott, 2004
Contact Info: www.ecu.edu.au/research/week
Collaborative Goal Setting
• Numerous calls to work
collaboratively
– Duchan & Black, 2001; Holliday, Cano, Freeman & Playford,
2007; McClain, 2005
• Policy directives
– Eg: National Stroke Foundation Clinical Guidelines for Stroke
Management 2010
• Therapeutic approaches which
incorporate collaborative goal
setting
–
–
–
–
Social approaches
LPAA
A-FROM
Byng & Duchan, 2005; Chapey et al., 2001; Simmons-Mackie,
2000
Contact Info: www.ecu.edu.au/research/week
But is it really happening?
• No....
– Rosewilliam, Roskell & Pandyan, 2011
• People post-stroke still have limited
involvement in goal setting
– Barnard, Cruice & Playford, 2010; Cott, 2004; Gustafsson & McLaughlin, 2009;
Holliday, Ballinger & Playford, 2007; Parry, 2004; Wressle, Öberg & Henriksson,
1999
• Clinicians control the goal setting process
– Holliday, Antoun & Playford, 2005; Levack et al., 2006, 2009; Playford et al.,
2000; Van de Weyer et al., 2010
• ...and there is little collaboration with people
with aphasia.
– Kuipers et al. 2004; Leach, Cornwell, Fleming & Haines, 2010; Parr, Byng, Gilpin &
Ireland, 1997
Contact Info: www.ecu.edu.au/research/week
Example
• Holliday, Antoun & Playford (2005)
– Questionnaire of 202 rehabilitation professionals
(mainly doctors)
– Nearly 50% used a problem-orientated approach to
goal setting
– Just over 40% used a client-centred approach
– Most reported giving no verbal or written information
to patients on goal setting
– Often discussed by team without patient present
– Only 50% gave patients a record of treatment goals
– 30% did not involve patients in any evaluation of
goals
Contact Info: www.ecu.edu.au/research/week
Reasons why professionals ‘own’
goal setting
– Playford et al. (2000):
•
•
•
•
Process is faster
Easier to ignore goals which seem too hard to work on
Having a team plan encourages patients to go along with it
Patients with communication difficulties can still be helped
achieve a goal even if they can’t understand or express it
• Goal setting helps teams work productively
Contact Info: www.ecu.edu.au/research/week
Goal setting is confusing for clients...
Contact Info: www.ecu.edu.au/research/week
...despite good intentions.
• Maybe we need to re-think how we can be more
collaborative in goal setting...
Contact Info: www.ecu.edu.au/research/week
Plan for this presentation
• Summary of findings from the Goals in Aphasia
Project
– What did people with aphasia want from
rehabilitation?
– What did family members want?
– What did speech pathologists do in goal setting?
– How do speech pathologists conceptualise a
goal?
• Explanation of SMARTER Goal Setting model
Contact Info: www.ecu.edu.au/research/week
METHODS
• Funding
– NHMRC – project grant with colleagues (Linda Worrall, Bronwyn
Davidson, Alison Ferguson, Tami Howe and Sue Sherratt)
• Design
•
Qualitative descriptive research strategy (Sandelowski, 2000)
• Participants
• 51 participants with aphasia recruited through community sources
• PWA nominated family members and their treating speech
pathologists
• Final sample
• 50 PWA (26 women, 24 men, mean age 63.9 years, mean of 54.3
months post onset, WAB mean 69.6AQ).
• 49 FM (36 women, 12 men)
• 36 SPs (32 women, 2 men)
Contact Info: www.ecu.edu.au/research/week
• Data collection
– Semi-structured in depth interviews by trained
experienced post doctoral speech pathology researchers
– Interviews of PWA videotaped, FM & SPs audiotaped, all
transcribed verbatim.
• Topics
– For PWA and FMs: what they wanted/what their goals
were at different stages of recovery, and what
experiences were helpful or unhelpful.
– SPs: goals for their clients, what they perceived their
clients’ goals to be, their definitions of goals, and
barriers and facilitators to goal setting.
Contact Info: www.ecu.edu.au/research/week
What do people with aphasia want?
1.
2.
3.
4.
5.
6.
7.
8.
9.
Return to pre-stroke life
Communication
Information
Speech therapy
Physical health goals
Social/Work Leisure
Control/Independence
Dignity/respect
Contribution to society
Contact Info: www.ecu.edu.au/research/week
Example: Return to pre-stroke life:...Back to
normal
• ...just to be normal and enjoy life. (Mavis)
• I trying to normal but not working. I want
to 100 cent again. (Christopher)
• I thought I, I will just get better. (Neville).
Contact Info: www.ecu.edu.au/research/week
What do family members want?
• For themselves:
– Information
• About the stroke, aphasia, prognosis, services
– Support
• Family, community services, financial
– Ways to communicate and maintain their relationship
with their loved one with aphasia
– To be included and involved in rehabilitation
– To have a sense of hope and positivity
– To take care of their own well-being
– To cope with new responsibilities
Contact Info: www.ecu.edu.au/research/week
What do family members want?
• For the person with aphasia:
– Survival
– Effective communication
– A level of independence
– To be able to handle emergencies
– Social opportunities
– Stimulation
– Meaningfulness in life
Contact Info: www.ecu.edu.au/research/week
What goals do speech Pathologists
set in practice?
Functional
therapy
Impairmentlevel
therapy
Education,
counselling,
family
involvement
Goals
Contact Info: www.ecu.edu.au/research/week
How do speech pathologists define
goals? (Hersh, et al. 2012 a)
• Six overlapping categories:
– Goals defined by the desires of
clients/families
– Defined through SMART concepts
– Goals as steps
– Representing different aspects of the ICF:
impairment or functional
– Goals as contracts
– Implicit goals
Contact Info: www.ecu.edu.au/research/week
Competing goals:
• Speech pathologists aspire to be person-centred
• But the goal setting process is dominated by the
need for goals to be SMART (professional-centred)
– Barnard, Cruice & Playford, 2010; Hersh et al., 2012a; Leach, Cornwell,
Fleming & Haines, 2010
Contact Info: www.ecu.edu.au/research/week
Focus on the steps or sub-goals...
Contact Info: www.ecu.edu.au/research/week
... So the big goals are not always
addressed
Contact Info: www.ecu.edu.au/research/week
SMARTER Goal Setting (Hersh et al., 2012b)
• New framework developed from Goals in
Aphasia Project
• Does not seek to replace SMART but these
goals can be negotiated in a SMARTER way
• SMART is about the nature of goals
• SMARTER is about the process of setting them
• SMARTER encompasses a set of values to
underpin a collaborative, responsive and flexible
goal setting process
Contact Info: www.ecu.edu.au/research/week
SMARTER goal setting
•Shared
•Monitored
•Accessible
•Relevant
•Transparent
•Evolving
•Relationship-centred
Contact Info: www.ecu.edu.au/research/week
Shared
Monitored
G
O
A
L
S
Accessible
Relevant
Transparent
Evolving
Relationshipcentred
Contact Info: www.ecu.edu.au/research/week
Specific
Measurable
Achievable
Realistic
Time-bound
Goal setting should be Shared
•Principles of shared decision-making (Charles et al., 1997; 1999)
• Understanding of each other’s perspective
• Real choices, real negotiation
• Some level of agreement
•Practical suggestions:
–Preparation of client and family for goal setting
• Goal setting folder? Pre-admission interview (if appropriate)?
–Orientation to rehabilitation context/staff/team and
expectations of both clients and staff
–Accessible information – range of media/aphasia friendly
–Increased time required
–Attendance and inclusion at meetings
–Aphasia friendly documentation and dissemination of discussions, goal
choices
–Effective interprofessional collaboration
Contact Info: www.ecu.edu.au/research/week
Example with person with aphasia
•I: OK. So her question "What do you want to work on?" that
woke it all up, did it?
•Alistair: Er, yes. Yeah, erm.
•I: That's interesting.
•Alistair: I felt so happy.
•I: Yes? That somebody had asked you what you wanted?
•Alistair: Yes, yes.
Contact Info: www.ecu.edu.au/research/week
Goal setting should be Monitored
• Why monitored rather than measured?
– Redirection of focus...
• Continuous evaluation
– Discussions of change (or lack of it) within therapy
– Not limited to discreet periods of
assessment
– Iterative approach, appraisal and feedback
– Shared aphasia friendly documentation of change
• Emphasis beyond numerically-based
change
– Encourages inclusion of activity and participation level
evaluation and feedback
– Includes client self-evaluation, family evaluation
– Helps avoid goal setting purely driven by an assessment
result which may not reflect client goals
Contact Info: www.ecu.edu.au/research/week
Goal setting should be Accessible
•Aphasia friendly, accessible processes are crucial to collaborative
goal setting
•Practical suggestions:
–Extra time
–Structured workbook prior to sessions
–semi-structured interview format using supported conversation
–Aphasia-friendly materials for negotiating original goals, showing how
goals split into steps, monitoring change, revising goals
–Accessible documentation and dissemination of
discussion
–“Talking mats” idea?
Contact Info: www.ecu.edu.au/research/week
Goal setting should be Relevant
•Practical suggestions:
–Don’t assume what is relevant for someone – work through it
together and keep checking
–Don’t only rely on assessment findings on
standard batteries to guide a starting point for
therapy
–Consider a home visit for someone in residential rehabilitation –
goal setting in an authentic context may be useful
–Involve family and friends where it is possible
–Ensure the therapy reflects the relevance of the
goals
Contact Info: www.ecu.edu.au/research/week
Example from a person with aphasia
They wanted to know what a horse was, what a
dog was, and animals… I know what a horse
was… I went to a room. They had, they said
‘horse’… and they said I must write ‘horse’…
But it wasn’t what I …. I wanted to read. But I
couldn’t read because it was just like pages and
pages and pages and I got fed up. (Edwina)
Contact Info: www.ecu.edu.au/research/week
Goal setting should be Transparent
•There need to be very clearly discussed
LINKS
– Between big goals and small steps or subgoals
– Between goals identified during goal-setting and the therapy
tasks/activities chosen
•There should be clear records of agreed goals
•Everyone should understand the rationale behind them and
know how they were chosen
Contact Info: www.ecu.edu.au/research/week
Establishing goals & subgoals (SLP
suggestions)
•Lots of talk
•Goals lists
•Visualisation, metaphor & analogy (steps, ladders, journey, bite-sized
chunks)
•Relating steps to client’s life & interests
•Making subgoals ‘outcome oriented’
•Working through
– hierarchy of everyday activities
– Modalities
– Prioritisation: rating tasks for importance
•Seeking regular feedback
Contact Info: www.ecu.edu.au/research/week
Goal setting should be evolving
•Goals change with time
•Goals need to be revised and revisited regularly
•Ensure clients are aware early that they can request
a change of direction
•Don’t assume goals in the early stages of recovery
must be impairment level and that later goals are
necessarily activity/participation
–Clients may have different priorities
•Don’t assume that client input is only possible once
people have made some recovery
Contact Info: www.ecu.edu.au/research/week
Goal setting should be
RELATIONSHIP-CENTRED
•Goal setting involves getting to know your client and
family so that plans for rehabilitation are well
grounded and informed
•Do not use a formal assessment session as a basis
for getting to know your client
Contact Info: www.ecu.edu.au/research/week
Conclusion
• Goal setting is often reported by clients and
families as confusing and they often feel excluded
• Professional tendencies to prioritise SMART ideals
have reinforced this
• SMARTER concepts increase awareness of the
potential for a collaborative process
• Many clinicians already use aspects of SMARTER
• But this framework engages a set of values,
attitudes and practical changes
Contact Info: www.ecu.edu.au/research/week
Goals are complex, multi-layered and
overlapping...
Contact Info: www.ecu.edu.au/research/week
But we need to aim high …
Contact Info: www.ecu.edu.au/research/week
References
•
•
•
•
•
•
•
•
•
•
•
•
•
Barnard, R.A., Cruice, M. & Playford, E.D. (2010). Strategies used in the pursuit of achievability during goal setting in
rehabilitation. Qualitative Health Research, 20, 239-250.
Byng, S. & Duchan, J. (2005). Social model philosophies & principles: Their applications to therapies for aphasia.
Aphasiology, 19, 906-922.
Chapey, R., Duchan, J., Elman, R., Garcia, L., Kagan, A., Lyon, J., & Simmons-Mackie, N. (2001). Life participation
approaches to aphasia. In Chapey, R. (Ed.), Language intervention strategies in aphasia and related neurogenic
communication disorders (4th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.
Charles, C., Gafni A., & Whelan, T. (1997). Shared decision-making in the medical encounter: What does it mean? (or it
takes at least two to tango). Social Science and Medicine, 44, 681–692.
Charles, C., Gafni A., & Whelan, T. (1999). Decision-making in the physician-patient encounter: Revisiting the shared
treatment decision-making model. Social Science and Medicine, 49, 651–661.
Cott, C.A. (2004). Client-centred rehabilitation: client perspectives. Disability and Rehabilitation, 26, 1411-1422.
Duchan, J.F. & Black, M. (2001). Progressing toward life goals: A person-centered approach to evaluating therapy.
Topics in Language Disorders, 21, 37-49.
Gustafsson, L., & McLaughlin, K. (2009). An exploration of clients' goals during inpatient and outpatient stroke
rehabilitation. International Journal of Therapy and Rehabilitation, 16, 324-330.
Hersh, D., Sherratt, S., Howe, T., Worrall, L., Davidson, B. & Ferguson, A. (2012a). An analysis of the “goal” in aphasia
rehabilitation. Aphasiology. 26/8, 971-984.
Hersh, D., Worrall, L., Howe, T., Sherratt, S. & Davidson, B. (2012b). SMARTER goal setting in aphasia rehabilitation.
Aphasiology, 26/2, 220-233.
Holliday, R.C., Antoun, M. & Playford, E.D. (2005). A survey of goal-setting methods used in rehabilitation.
Neurorehabilitation and Neural Repair, 19, 227-231.
Holliday, R.C., Cano, S., Freeman J.A. & Playford, E.D. (2007). Should patients participate in clinical decision making?
An optimised balance block design controlled study of goal-setting in a rehabilitation unit. Journal of Neurology,
Neurosurgery and Psychiatry, 78, 576-580.
Kuipers, P., Carlson, G., Bailey S. & Sharma, A. (2004). A preliminary exploration of goal-setting in community-based
rehabilitation for people with brain impairment. Brain Impairment, 5, 30-41.
Contact Info: www.ecu.edu.au/research/week
References
•
•
•
•
•
•
•
•
•
•
•
•
Leach, E., Cornwell, P., Fleming, J. & Haines, T. (2010). Patient centered goal-setting in a subacute
rehabilitation setting. Disability and Rehabilitation, 32, 159-172.
Levack, W. M., Dean, S. G., McPherson, K. M., & Siegert, R. J. (2006). How clinicians talk about the
application of goal planning to rehabilitation for people with brain injury - variable interpretations of value and
purpose. Brain Injury, 20, 1439 -1449.
Levack, W. M., Siegert, R. J., Dean, S. G., & McPherson, K. M. (2009). Goal planning for adults with acquired
brain injury: How clinicians talk about involving family. Brain Injury, 23, 192-202.
McClain, C. (2005). Collaborative rehabilitation goal-setting. Topics in Stroke Rehabilitation, 12, 56-60.
McLellan, D. L. (1997). Introduction to rehabilitation. In B. A. Wilson & D. L. McLellan (Eds.), Rehabilitation
Studies Handbook. Cambridge: Cambridge University Press.
National Stroke Foundation (2010). Clinical Guidelines for Stroke Management 2010. Melbourne, Australia.
Parr, S., Byng, S., Gilpin, S., & Ireland, C. (1997). Talking about aphasia: Living with loss of language after
stroke. Buckingham: Open University Press.
Playford, E. D., Dawson, L. K., Limbert, V., Smith, M. C., Ward, C. D., & Wells, R. (2000). Goal-setting in
rehabilitation: report of a workshop to explore professionals' perceptions of goal-setting. Clinical
Rehabilitation, 14, 491-496.
Playford, E. D., Siegert, R., Levack, W., & Freeman, J. (2009). Areas of consensus and controversy about
goal setting in rehabilitation: a conference report. Clinical Rehabilitation, 23, 334-344.
Rosewilliam, S., Roskell, C.A., & Pandyan, A.D. (2011). A systematic review and synthesis of the quantitative
and qualitative evidence behind patient-centred goal setting in stroke rehabilitation. Clinical Rehabilitation,
25, 501-514.
Van de Weyer, R.C., Ballinger, C. & Playford, E.D. (2010). Goal setting in neurological rehabilitation: staff
perspectives. Disability and Rehabilitation, 32, 1419-1427.
Wade, D.T. (2009). Goal-setting in rehabilitation: an overview of what, why and how. Clinical Rehabilitation,
23, 291-295.
Contact Info: www.ecu.edu.au/research/week