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), youâll 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 âpillar of rehabâ is likely to change in the future.
Letâs dive in.
Who had the audacity to tackle this topic?
This article is the first weâve 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 itâs the highest quality around.
As weâll 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:
- Is a structured approach to goal setting better than no goal setting at all?
- Is a structured approach to goal setting better than âusual care?â
- Are interventions that enhance goal pursuit better than doing nothing?
- 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 patientsâ lives should be the focus of every step of the rehab process. Thatâs 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)
- âSMARTâ goal planning (often interpreted to refer to âSpecific, Measurable, Achievable, Relevant, and Time-Limited)
- âRUMBAâ goal planning (often interpreted to mean âRelevant, 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 (PGAPâ˘)
- 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 âICF Rehab Cycleâ
- 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?
- 10-Meter Walk Test
- Barthel Index for Activities of Daily Living (BI)
- Biering-Sorensen test
- Canadian Occupational Performance Measure (COPM)
- Chronic Disease Self-efficacy Scale
- Chronic Respiratory Questionnaire
- Client Motivation for Therapy Scale
- Cognitive Coping Index
- Commitment Scale of the Work Values Inventory
- Dallas Pain Questionnaire
- Depression Anxiety Stress Scale (DASS)
- Derogatis Stress Profile Instrument (DSP)
- Frenchay Activities Index (FAI)
- Functional Independence Measure (FIM)
- General Health Questionnaire (GHQ)
- General Self-Efficacy Scale (GSE)
- Global Severity Index
- Goal Attainment Scaling (GAS)
- Griffiths Work Performance Scale
- Health Assessment Questionnaire- Disability Index
- London Handicap Scale (LHS)
- Minnesota Living with Heart Failure
- Modifiable Physical Activity Questionnaire
- Neurobehavioral Functioning Inventory (NFI)
- Pain Behaviour Questionnaire/Scale
- Pain Catastrophizing Scale (PCS) (child version and parent version)
- Pain Disability Index
- Patient Participation Scale
- Patient Perception of Rehabilitation
- Piper Fatigue Scale (PFS)
- Positive and Negative Affect Scale (PANAS)
- Psychological Responses to Sports Injury Inventory
- Roland Morris Disability Questionnaire
- Rosenburg Self-esteem Scale
- Satisfaction with Life Scale
- Shepherd Social Behaviour Rating Scale
- Short Form 36 - Physical Component Summary Score
- Short Form 36 - Mental Component Summary Score
- Sickness Impact Profile (SIP)
- Sports Injury Rehabilitation Adherence Scale (SIRAS)
- Sports Injury Rehabilitation Beliefs Scale/Survey
- State Trait Anxiety Inventory
- Tampa Scale of Kinesiophobia
- Timed Up and Go Test (TUG)
What were the results?
OK, going back to the 4 main questions the researchers sought to answer, hereâs what they found:
1. Is a structured approach to goal setting better than no goal setting at all?
The authors found âvery low-qualityâ 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 âusual care?â
The authors found âvery low-quality evidenceâ 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 âvery low-quality evidenceâ 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 doesnât 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. Thatâs 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 formationâmaybe 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 Yearâs Goals have gotten a bad rap over timeâthey just donât 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, youâre 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: âattention to behavior change strategiesâ supports the type of goal pursuit that seems to be most effective.
Weâve 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:
- Shared decision making within goal setting in rehabilitation settings: A systematic review (2017)
- Goal-setting in geriatric rehabilitation: a systematic review and meta-analysis (2018)
- A review of goal setting theories relevant to goal setting in paediatric rehabilitation (2019)
Iâm looking forward to discussing this topic with you today, and when it comes up again!!
Hereâs 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