Goal setting provides incentive, improves adherence, and helps measure progress. Right? Maybe. Presenters in the session “Goal Setting in Rehabilitation: Theory, Practice, Evidence” at the annual American Congress of Rehabilitation Medicine conference in Toronto were consistent in their believe that goal setting is important for rehabilitation but also pointed out a lack of evidence and a distinct lack of consistency in application. It seems that goal setting theory in healthcare has been largely borrowed from business and sports, and while it makes sense that goal setting should help patients, there is not a lot of decisive evidence and there is a lot of debate on how goals should be set.
Does goal setting work?
A survey of the clinical research on goal-setting in rehabilitation showed that goal setting didn’t improve physical function, however it did improve patient self-efficacy. Evidence was inconclusive on whether goal setting affected motivation, adherence, or engagement. However, the overall analysis showed a statistically significant difference in favor of goal setting. The issue is how goals are set and could setting them differently improve care.
How are goals set?
Currently the usual care condition for setting goals is having healthcare professionals set them instead of patients. The problem with this is that the goals may be SMART, but they are not meaningful for the patients. There is often a mismatch between patient and physician goals: physician goals are often functional goals and patient goals are quality of life or aspirational goals. Since goal seems to have a bigger impact on intrinsic factors, like efficacy and possibly also satisfaction, it seems that patient-directed goals would be more effective.
The following are “SMART goals” adapted to apply in rehabilitation. However, the speakers adapted them slightly to apply more directly to rehabilitation. (Assignable rather than achievable.)
How should goals be set?
Goals that help a patient connect with their care plan are preferred, for example, goals that fit the following criteria.
While presenter Kath McPherson from the Auckland Institute of Technology argued that patient goals could be vague and also asked why goals had to be realistic: wasn’t it better that the patient continued to hope and work towards something, William M. M. Levack the concept of helping patients set “fiduciary” goals. That is, guide the patients goals based on the situation more initially and less as the patient gained autonomy. To illustrate this he used the example of Mr Roberts a blind diabetic amputee who had a goal of going home to live. If Mr. Roberts’ goal were the only thing taken into consideration, it would ignore the realistic factors that might not make this possible, for example, his wife’s ability to care for him. As such, a better approach for goal setting for Mr. Roberts was to consider a number of factors including:
- The values and preferences of the patient
- Clinical judgment of the healthcare professional
- Time and resources required for the goal
- Likely consequences of pursuing the goal
For Mr. Roberts, this approach would look like this:
The takeaway from these sessions was the necessity to link the clinicians small functional goals with the patients big aspirational goals. Functional goals are necessary and will measure progress but aspirational goals are what drives patient self efficacy which is so important for recovery.
We think a lot about goal setting and patient reported outcomes at Wellpepper. Patient reported outcomes are great tools to show progress and also validate clinical efficacy but they must be linked to patient’s goals for real impact. We’re working on some interesting ways to do this through our technology and are excited to be able to share this with the rehabilitation medicine community.