Rehabilitation Goal Setting: Theory, Practice and Evidence PDF

Foreword

A speciality is defined by specific knowledge and skills. Rehabilitation is, arguably, defined by three features. First, the process of rehabilitation is set within a holistic, biopsychosocial model of health and illness. Second, multidisciplinary teamwork is crucial, and single disciplines cannot deliver rehabilitation. And third, setting goals for patients is the central skill and process; without this skill, a clinician cannot deliver effective rehabilitation.

This book is, to the best of my knowledge, the first comprehensive scientifically based text to cover goal setting within the context of rehabilitation, and it is probably the first within the context of healthcare. Moreover it demonstrates, implicitly, the need to use the biopsychosocial model of illness that is exemplified by the World Health Organization's International Classification of Functioning, Disability and Health. It also, inevitably, considers how goal setting is a necessary part of multidisciplinary teamwork.

Rehabilitation is a process that aims to alter behaviour in the sense that it intends to change how a patient undertakes activities and/or change how others assist a patient in achieving his/her goals. This is why goal setting with a patient is so important - behaviour refers to actions that are undertaken to achieve some goal, be it immediate or long term. Therefore, the process of rehabilitation is centred on patient goals and patient activities.

One other group of medical specialities has a very similar focus – psychiatric or mental health services including those for people with learning disabilities. Although some services, possibly the majority in some countries, have adopted a very biological approach to psychiatric illness, the reality is that most clinical focus is on altering behaviour and helping people adapt and manage their long-term problems.

Consequently, this book should be read not only by anyone involved in any medical rehabilitation service but also by anyone involved in psychiatric and mental health services. Why?

Within the 19 chapters there is an extensive review of evidence about and discussion of the various theories that concern altering behaviour. This is all set in the general context of healthcare, although most of the original hypotheses and related evidence come from other spheres including management and sports sciences. The book draws upon a broad range of material, interpreting it in the particular context of rehabilitation.

There is also an extensive review of the evidence concerning the effectiveness of goal setting in improving the efficiency and effectiveness of rehabilitation. Most readers will not be surprised to learn that the evidence base is quite patchy and weak, although the evidence available certainly suggests that it is beneficial rather than harmful.

Recognizing the need for much more research, and recognizing that there are considerable challenges in undertaking this research, this book also discusses how the evidence base could be improved. The last chapter, which particularly discusses this, is based on the personal experience of the two editors. It should be read by anyone setting out to undertake research in this difficult field.

The book is also intended to help practicing clinicians and rehabilitation teams in their day-to-day work. The acronym most often associated with goal setting is SMART, and the authors agree with me that this is not necessarily a useful acronym. For a start, there is not even any agreement on what the letters stand for: is ‘A' appropriate or achievable or attributable, and is ‘M' measureable or meaningful?

Another commonly used acronym is GAS – goal attainment scaling – which refers to a method for scoring how well a person succeeds in achieving goals set. The process of using GAS probably increases patient engagement provided that it is not used to measure outcome at a group level or in relation to payment. Again, this process is discussed extensively in the book.

Within the book there are several discussions on the use of goal setting in different contexts, both clinical and cultural. For example, its application in people who have good cognition and communication is discussed, but also its application in people without full mental capacity such as children, or people with aphasia.

One interesting new idea is introduced – the importance of meaning in the process of setting goals. Although the ideas need further investigation and development, the central importance of meaning has been translated into a new acronym, MEANING. Although I have an intrinsic dislike of acronyms, this one avoids a simple letter-to-word translation and instead uses the acronym to propose an approach.

Another specific area that is discussed is the use of goal setting by patients who are taught self-management. This is likely to become increasingly important, and there is some evidence supporting its effectiveness, for example in people with chronic fatigue syndrome and other functional illnesses.

One very unusual aspect of this book, which is to be commended, is that it discusses the interaction between the goal setting process and ethical clinical practice. The first part of this discussion concerns a detailed description of one widely used approach to analysing ethical issues in any clinical practice, particularly relating this framework to rehabilitation practice.

I think that it is very important that all clinicians, and indeed all people working in healthcare, are familiar with an approach to analysing ethical issues. Even more important, all healthcare staff must be alert to the existence of the ethical dimension of each and every decision made about both individual patients and about services and groups of patients. This chapter should remind all readers of their responsibility.

However, the really interesting challenge is a claim that there is an ethical imperative to undertake goal setting with every patient (in rehabilitation). I would agree that there is a moral, professional requirement to establish with every patient what their wishes and expectations are; this is legally reinforced in many countries by statutes such as the Mental Capacity Act (2005) in England and Wales. I would also agree that without knowing these facts, any attempts to improve activities are likely to be less successful.

Nonetheless, I am less convinced that there is an additional moral imperative to engage the patient further in the goal-setting process. The authors may be correct, but I think at present we lack the evidence to support such a claim. I recommend each reader to read that chapter, especially its ending (see Chapter 4, Ethics and Goal Setting).

This book both excited and educated me from the moment I first read it. I had naively thought that I knew much about goal setting and had, in a rather self-centred way, considered that we at the Rivermead Rehabilitation Centre had developed the process not from scratch, but certainly from a low base. I now know that goal setting was being used well before I started in rehabilitation (in 1980), and I now know much more about its theoretical basis, its evidence base, and I have learned new ideas about its use.

I think that this book should be read by every team member from every involved profession - nurses, doctors, social workers, dieticians, physiotherapists, speech and language therapists, clinical psychologists, occupational therapists and so on.

Even more importantly, the people who manage rehabilitation services and the people who pay for rehabilitation services should also read this book. As professional managers, they will immediately recognize the process. On reading the book they will gain a useful insight into rehabilitation and, hopefully, they may well be able to help the clinical service improve still further in the process of goal setting.