Goal setting has been defined as “the process during which patient and clinical members of the multidisciplinary team make a collective decision, following an informed discussion, of how and when to carry out rehabilitation activities” (Rosewilliam et al., 2011).
Goal setting (or goal planning) is a central component to rehabilitation. It ensures explicit identification of the reasons for all activity and a way in which to monitor achievements (Wade, 2009).
Within stroke rehabilitation, there are a variety of ways a clinician may undertake goal setting which is dependent on factors such as:
There are various formal and informal approaches to goal setting, with limited guidance regarding the most beneficial approach or theoretical framework. As evidenced by clinical guidelines, current rehabilitation practices strongly encourage the incorporation of client and family perspectives within a team-based approached to goal setting (National Stroke Foundation, 2010). This shift away from medically led approaches to a broader, more inclusive view of health, places an emphasis on the client’s preferences and the involvement of their family.
A key first step in the goal setting process is to understand the different perspectives of what a 'goal' is. Click on the links below to obtain insight into the perceptions of goals from the perspectives of:
There is wide consensus within the Australian Stroke Guidelines working party and the literature that goal setting is beneficial for the rehabilitation process and should always take place with the stroke survivor and/or family/carer (National Stroke Foundation, 2010).
Levack et al’s (2006) systematic review provides the most robust synthesis on the effectiveness of goal planning within rehabilitation to date. The authors included 19 randomised control trials (RCTs) from studies investigating a wide range of populations including stroke. There was some evidence that goal planning improves adherence to treatment regimes over the duration of a whole rehabilitation program and strong evidence that (for populations of people with acquired brain injury) prescribed, specific, difficult goals result in better immediate performance on motor and cognitive activities (Levack et al., 2006). Evidence regarding how these effects translated to improved outcomes following rehabilitation programs was inconsistent.
Levack et al (2006) further discuss that there are multiple purposes and, therefore, potential benefits to goal setting. In addition to improving client outcomes on standardised measures, goal setting is also thought to be a good framework for evaluation of outcomes, for enhancing client autonomy or ‘client-centred’ therapy, team work and for demonstrating accountability to contractual, legislative or professional standards.
Goal setting with stroke patients with aphasia can be difficult due to:
language impairments - this makes expressing needs difficult, and discussion of experiences and needs can be a long and convoluted process
cognitive capacity issues - although most people with aphasia should be viewed as competent partners in decision making about their needs, compounding capacity issues can arise particularly in the early stages post-stroke
the abstract concept of aphasia and poor awareness of the condition
feelings of disempowerment - often arise when communication is impaired
age of clients - clients are often older and may expect to be directed in therapy rather than consulted
the medical setting - this setting may reinforce a culture in which speech pathologists focus on impairment
(Adapted from Worrall et al., 2011)
A variety of barriers to client-centred goal setting have been described in the literature such as in Rosewilliam et al., 2011. Despite these reservations, where professionals made efforts to involve clients in the goal setting process, the clients, recognising the importance of their involvement, were able to contribute effectively (Rosewilliam, et al., 2011).
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Professor Linda Worrall