Goal setting and strategies to enhance goal pursuit for adults with acquired disability participating in rehabilitation

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Read Full Text: Goal setting and strategies to enhance goal pursuit for adults with acquired disability participating in rehabilitation (Free to access)
Journal: Cochrane Database of Systematic Reviews
Year Published: 2015
Ranked 31st on our 2015-2020 list of the 100 most influential OT-related articles

As rehab professionals, we see goal setting as fundamental to delivering excellent care. And, considering all the time and effort we devote to setting goals with our patients, surely there is solid evidence to support the practice, right?!?!

Or is there? Does the research even back the need to set goals in the first place?

While the answer may seem disappointing (hint: there is only very low-quality evidence that indicates setting goals improves outcomes), you’ll feel thankful for the time you spend with this research. Not only will it orient you to our current predicament with goal setting, it will also provide a preview of how this “pillar of rehab” is likely to change in the future.

Let’s dive in.

Who had the audacity to tackle this topic?

This article is the first we’ve looked at from the Cochrane Library.

If you are not familiar with the Cochrane Library, the type of research they produce is considered the apex of the evidence pyramid, meaning it’s the highest quality around.

As we’ll see today, Cochrane is not afraid to tackle the tough topics and really delve into them. (This article is 169 pages long!)

What was the aim of this article?

The aim of this research seems simple enough:

To assess the effects of goal setting (and strategies to enhance goal pursuit) on health outcomes for adults with acquired disabilities who are participating in rehab.

They looked at this from four different angles, notably:

  1. Is a structured approach to goal setting better than no goal setting at all?
  2. Is a structured approach to goal setting better than “usual care?”
  3. Are interventions that enhance goal pursuit better than doing nothing?
  4. Is there one structured approach to goal setting that is better than another?

A little background on goal setting in rehab

Now, goal setting has multiple functions in the rehab setting. Not only does it help us track outcomes, it can also serve as a tool to get practitioners, patients, and caregivers on the same page.

At the end of the day, improving our patients’ lives should be the focus of every step of the rehab process. That’s why I was so thankful that the authors of this article chose to focus on whether the process of goal setting actually improves health outcomes.

The authors gave a helpful background on WHY we believe that goal setting helps improve outcomes, as well as some of the current strategies being used to set goals.The processes behind goal setting vary more than you may realize. Just to give you a sample, here are the different structures to goal setting that were mentioned in the article:

  • Goal Attainment Scaling (GAS)
  • Goal setting based on the Canadian Occupational Performance Measure (COPM)
  • “SMART” goal planning (often interpreted to refer to “Specific, Measurable, Achievable, Relevant, and Time-Limited)
  • “RUMBA” goal planning (often interpreted to mean “Relevant, Understandable, Measurable, Behavioral, and Achievable)
  • Self-Identified Goal Assessment (SIGA)
  • Goal Management Training (GMT) and Identity-Oriented Goal Training (IOG)
  • Approaches to goal planning from the Wolfson Neurorehabilitation Centre
  • Contractually-organized goal setting
  • Collaborative Goal Technology
  • Goal setting as part of the Progressive Goal Attainment Program (PGAP™)
  • Patient-centered functional goal planning
  • Goal setting based on the Patient Goal Priority Questionnaire (PGPQ) or Patient Goal Priority List (PGPL)
  • Goal setting based on the “ICF Rehab Cycle”
  • The TARGET Method of Goal setting
  • The Goal-Setting and Planning Skills (GAP) Program

What research did they find to examine?

In their systematic review of research, the authors found 39 randomized controlled trials (RCTs) that specifically examined the impact of rehab goal setting on health outcomes.

What assessments were they using for outcome measures?

What were the results?

OK, going back to the 4 main questions the researchers sought to answer, here’s what they found:

1. Is a structured approach to goal setting better than no goal setting at all?
The authors found “very low-quality” evidence that goal setting results in a moderate increase in health-related quality of life, as well as a large increase in patient self-efficacy.

However, no evidence was found to support an effect on:

  • Activity levels
  • Improvement in body structure or body function
  • Levels of engagement in rehab

2. Is a structured approach to goal setting better than “usual care?”
The authors found “very low-quality evidence” that using more structured approaches to goal setting results in a moderate increase in self-efficacy.

No evidence was found to support more structured goal setting versus usual care, in terms of:

  • Health-related quality of life
  • Patient-reported emotional status
  • Activity levels

3. Are interventions that enhance goal pursuit better than doing nothing?
There is “very low-quality evidence” that using information technology (text message or portable voice organizers) improved the ability of people with brain injuries to recall their rehab goals.

4. Is there one structured approach to goal setting that is better than another?
There was insufficient data to draw conclusions on this question.

What did the authors conclude/discuss?

The bad news is that, ultimately, the authors concluded that:

Convincing, high-quality evidence on the effectiveness of goal setting interventions was lacking.

But, that doesn’t seem to mean we should give up on goal setting. Structured goal setting seems to have the best outcomes; this type of goal setting is characterized by:

  • Higher levels of patient participation in goal selection
  • Greater emphasis on personally meaningful outcomes
  • Attention to behavior change strategies

The authors make this suggestion for how the research should impact our practice:

We could speculate that the emphasis on person-centeredness and personally-meaningful goals has favored outcomes related to subjective rating of quality of life, feeling of personal control, and high satisfaction with service delivery but has not favored outcomes related to physical performance of activities or objective measures of social participation.

Takeaways for OT practitioners

1. Incidentally, the areas where goals seem to be most effective = great news for OTs!

Honestly, if I were a PT reading this, it would make me nervous. That’s because the authors straight-up say that the impact of goal setting seems to be on psychosocial outcomes, not physical outcomes.

As OTs, we should see this as validation of our work. The psychosocial domain is our jam. Areas like promoting self-efficacy and overall quality of life are well within our domain. You might even notice that working with our patients explicitly on the psychosocial aspects of healing is something we see mentioned over and over again in the Club!

2. In the self-help world, traditional goal setting is taking the backseat to habit formation—maybe we will see the same in rehab?

It feels like in the self-help world, people have come to accept that simply setting goals is not enough. Things like New Year’s Goals have gotten a bad rap over time—they just don’t seem to work!

What is growing in popularity is an emphasis on habit formation. (For example, if you focus on replacing your afternoon sodas with a yummy sugar-free alternative, you’re more likely to lose weight than if you just declare you are going to lose 10 pounds.)

With this in mind, I really keyed in on the fact that the authors suggested that: “attention to behavior change strategies” supports the type of goal pursuit that seems to be most effective.

We’ve talked about habits and behavior change several times in the Club, and I can definitely see habit formation as a natural future for the focus of OT. After all, what are our habits but the building blocks of our daily occupations?

3. This is JUST THE BEGINNING of the conversation on goal setting!

I almost skipped this article since 2015 feels so long ago. But, when I looked through the other research out there on goal setting, I felt like this was a foundational article that will really help us understand goal setting when it comes up again in Club. If you are eager to dive deeper into the new research today, here are some interesting-looking options I found:

I’m looking forward to discussing this topic with you today, and when it comes up again!!

Here’s the full APA citation for this article:

Levack, W. M., Weatherall, M., Hay-Smith, E. J., Dean, S. G., Mcpherson, K., & Siegert, R. J. (2015). Goal setting and strategies to enhance goal pursuit for adults with acquired disability participating in rehabilitation. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd009727.pub2

What questions/thoughts does this article raise for you?

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Sometimes we forget as therapists that we make goals that we want them to achieve. It is collaborative relationship between a therapist and a patient(or caregiver)
Also, goals are very dynamic and always changing along with the human behavior.
I was surprised to see I only used 2-3 out of the highlighted assessments. hmmm makes me want to explore them to see which one is more appropriate for my clients… perhaps give them a choice which should be use.

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@rhonda what a fun idea to give the client a choice in which assessment to use (given they understand a bit about the choices of course)! I dig it and amen to wanting to explore that list more.

This article and that idea reminds me of an old idea I have yet to act on of making a “menu” to use with clients of services that I can provide as a home health OT, including the habits I can help them work on/address.

Here’s a question, esp for those in home health, how can we most influence habit formation (aka behavior change) which IS beneficial and supported as effective by research, with little time with clients? Some HH OTs are getting 1x with a client only every OTHER week or LESS. What have others tried or thought of trying that could be helpful in supporting clients with habit change with limited overall contact?

Of course I think of using phone call check-ins and perhaps giving THEM homework to either do reading on the topic (of habit formation) and do research at least 3 ways THEY would like to track their habits.

What else might work? And what a wild turn of research results. @SarahLyon I did not expect the results, yet how freeing to pivot more towards what DOES work. Thank you again!

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I love that you brought up new year resolutions in your commentary about this article. I love coming up with new year resolutions but what’s more important are the systems I have to put in place in order to reach these goals. These systems or habits are the steps to living a life you want. Dreaming up big goals will not be helpful if there is no consistent action taking toward them.

Maybe a daily habit tracker would be helpful? The client would simply check off the days they engaged in the habit. The OT and the client could review the tracker and discuss challenges.

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As an OT who was a complementary alternative health care practitioner for about a decade before becoming an OT I have a different Hx of goal writing. I used to write goals for my clients that were more general. I would encourage 2-4 goals solely expressed by the client. I would encourage it to be a mix of clear biomechanical goals and more esoteric goals (ie. I want to feel more whole in my body, or I want to feel more balance). I would use these goals initially to help inform my work and if I saw other goals that I had for that person this process would be the opportunity to share them. I would then revisit those goals at least two times once in the middle of care ( I usually saw clients for 12 sessions) and once towards the end. I found that goal writing was useful for three reasons. One was to make sure that my focus and the client’s focus was in line and that the client felt like a partner in care. Another was to track progress. The third which I found the most interesting was to see how the goals changed over time. I often would have a client who would report for example in the initial goals that they wanted to resolve there back pain, have more movement in their ankle, and feel more “in balance” in their bodies. Halfway through the 12 sessions serries when I would check in with this same client they would report they might complain that there back still hurt and that there still having trouble sleeping. I would point out to them that sleep was not something they mentioned before and that they seem to have forgotten altogether that their ankle was ever a concern. Also, they might report feeling more “in balance”. This person who initially felt demoralized that there back still hurt then realize that they have already seen gains in their overall wellness and have started making new goals that were not priorities before.

Once I started writing goals as an OT my focus shifted from these less measurable client written goals to goals that would stand up to insurance billing scrutiny. I have seen no real improvement with this new goal method and in some ways feel like it has made outcomes too measurable and linear and has not held room for less measurable feelings like being “in balance”. I feel like as OTs we often get bogged down with assessments and paperwork for its own sake and can forget that the goal is the therapy, not the documentation.

Looking at the research results I wonder if the more structured goal writing gives more self-efficacy because the structure itself is useful or if that increase in self-efficacy is solely because more time is spent on goal writing.

What type of goals do you think most increase self-efficacy?

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As an OT providing early intervention, the emphasis on following family priorities for “goals ” or “outcomes “ has evolved in the past 10 years or so with coaching and routines based planning as the main means of intervention. I think we as OT’s are not new to client involvement in choosing what they want to achieve through therapy and how they want to do it. I think this research supports our core ideals of occupation based, client centered care within the context of each person’s unique environments. It will be interesting to see how this evolves and how it affects reimbursement. I teach as an adjunct in an OTA program. The course I am currently teaching is documentation with emphasis on the SOAP note. There are several lectures in goal setting and “SMART” and COAST and RHUMBA goal setting frameworks. As I teach these, this research will help me tailor the instruction. Specifically I will try to make sure that students really empathize client participation in outcome setting for their OT intervention process. Interesting. Thanks, Dr. Stephanie Bruggman

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This was a really interesting read and I guess something that I don’t actively think about as much as I could.

I personally set multiple goals with my client to make sure I am delivering client-centered care and to assist in progress tracking to show improvement, but I have never sat down and really focused on the impact this may be having in terms of psycho-social and physical results. I feel for me, at least in the way I practice, goals are a good way to track progress, yes, but it really gives a client a sense of being heard and acknowledged. Which lines up with what Irvin noted and even harks back to the participatory medicine article review from a couple weeks ago.

I am also intrigued by the idea of habit formation taking over the traditional goal setting process. Although my time in the field of OT is short as a recent graduate, I have noticed that when clients with low self-efficacy create a SMART goal it tends to have a high chance of backfiring and making it harder to reach that goal as it has an intimidating deadline. For instance, I have had several clients with depressive and anxiety diagnoses who have had increased difficulty with getting to sleep due to poor sleep hygiene. At first we approached with the generic “we need to focus on getting to be at a good time and to not use screens before bed” resolution (that sounds a bit harsher than the actual approach taken), but this tended to result in no change as clients would put too much pressure on themselves. Instead I changed the approach to allow for gradual changes to their current pattern and noticed a change in sleep patterns rather quickly. I guess in a way this comes back to the idea of grading and adapting in the sense we can control the exposure as to not shock the system, so to speak. I definitely feel that this point has a lot of merit.

I am really interested to see what goals other professionals are using to monitor and increase self-efficacy as well.

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Sarah,
This article gives the OT practitioner much to consider regarding goal setting. As with Dr. Bruggman, my textbook teaches the COAST model of goal setting. But, I agree with the discussion here, and that is, once again, the uniqueness of OT practice is highlighted in the research. OT practitioners create measurable goals that are client-centered, and there was evidence-based on client input on the goals set. The authors indicate that a higher level of client participation in goal setting and focusing on meaningful outcomes was their ‘take away.’ Lastly, they support behavioral changes that usually result from changed ‘habits.’ OT practitioners see routines and the environment vital to our treatment. Again, we should be excited and should grab onto this success. Behavioral approaches like collaborating with clients to create client-centered goals, focusing on client desired outcomes, and problem-solving adaptations to routine to support life quality are OT!
The Client Motivation for Therapy Scale is a tool I have used with middle school and high school students with a little tweaking to meet their needs. Here parents want different outcomes from students but ultimately, the adage that ‘we can lead a horse to water but can’t make them drink’ is appropriate here. Hence, I used the scale to help the students decide what methods to use to meet their IEP goals related to the organization, turn in homework, and complete written assignments. Of course, I had the added unwritten motivation that all of these skills were needed for high school graduation, which all wanted to complete. But, giving the student a voice in their therapy improved my outcomes.
I found this chapter that talks about client motivation outcome measures that is public domain.

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Hey @monika ! I was exploring some of the assessments today, and wondered if the Chronic Disease Self-efficacy Scale might be a good fit for HH? It is only 6 questions and appears to be publicly available.

Can you see it being helpful in your practice?:

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Dear all,
Since we are talking goals, check out the recently released study of an OT practitioner’s handwritten notes vs electronic documentation. I connected with the information related to goals which tremendously improved with electronic documentation. The study is a case study of one practitioner but I found the results worth considering.

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I’m LOVING this one! I love the reference to habit formation rather than goal setting. I read BJ Fogg’s Tiny Habits a year or two as a self development activity. And don’t get me wrong the personal implications are great but the application to OT practice was unmistakably HUGE. One of the biggest take aways from that text was that behavior is more than ABC, which is one of my biggest soap-boxes with some behaviorists- if they could do it, there’s a good chance they would do it! The Fogg model incorporates the huge implications of motivation as well as ability. It’s a great read for anyone looking to learn more about habit formation, and the audiobook was very engaging.

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Hey @sherry, do you remember where you found the Client Motivation Therapy Scale? I found some research articles about it, but couldn’t find it anywhere else! I love how you used it in the school setting!!

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I read about it in the AOTA publication, Brief motivational interviewing: A tool for OT practitioners published in the SIS quarterly Practice connections, 4(3), 16-18. They offer a rating on a scale of 0-10 on the individual’s thoughts regarding the ingredients of performance change including motivation, confidence, access to resources, commitment, and clarity of plan. They also suggest identifying Barriers to moving forward. https://www.aota.org/publications-news/sisquarterly/health-wellness-practice-connections/hchsis-8-19.aspx

Mahle and Ward cover this in the textbook Adult Physical Conditions: Intervention strategies for the occupational therapy assistant, p. 649-6651 with the COPM.

The model uses the following questions:

  1. On a scale of O-10 ( 10 being the highest) rate how important it is to make an identified behavior change ( e.g. physical activity, weight loss, improved medication management)
  2. What are the health benefits of making this change?
  3. When do you want to take action to make the behavior change?
  4. What barriers have limited your success in the past to make the identified change?
  5. On a scale of 0-10 rate how confined you are to carry out the identified behavior change.
    https://sphweb.bumc.bu.edu/otlt/mph-modules/sb/behavioralchangetheories/behavioralchangetheories6.html

I used something more simple like

tracking motivation.PNG
tracking motivation.PNG737×445 107 KB

I do not seem to be able to place my fingers on the actual Client Motivational Scale. Like you a quick Google search only supplies me with articles.

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Wow. @SarahLyon That chronic disease self management scale would work and at very least be worth try! Holy buckets—and the other 10 point scales referenced by @sherry are super exciting to consider trying because of both the objectivity AND client specificity. Though I can hear my leadership asking, Are the skills of aN occupational therapist needed to complete these?

How would y’all respond to this question?

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Ohhh good question, I’ve been thinking on in for a couple days!

I think I would respond to that question, that as an occupational therapist, it is our duty to follow the evidence and best practices for our patients (which is a highly skilled and complex undertaking). We’ve totally lost our way if we are doing doing unnecessarily complex assessments for the sake of third parties.

In the we research we consistently see the importance of actively partnering with our patients and boosting their self-efficacy, and part of that is using assessments that they can actively take part in! I’d challenge your leadership to point you to evidence that shows something different :slight_smile:

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Great thoughts! The first thing that came to mind when reading this was “Occupational Therapy provider’s have the MOHO in their back pocket to drive client centered goals (rather than therapist centered). Such a great reminder that our practice is effective from a psychosocial basis and we can more effectively support clients when THEY remain in the driver seat and we are just a guide providing options

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Mm. Well put. The humbling truth in all this is the value of time–and how true change takes time, take conversation, takes conversation. None of which am I paid for in my current “pay per visit” set up in home health. Excuse? No. Challenge and reality? Yes. Worth it? Yes.

The growing voice of confidence within me struggles with predicting their response (to be something towards pointing me to spending even MORE time advocating for change to higher levels) and already feeling defeated.

A new mindset recently though inspires me to go and try. See what happens.

Thank you for your feedback in how to professionally handle potential push-back with advocating for change.

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