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Patient engagement and satisfaction with goal planning: Impact on outcome from rehabilitation

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Aim: To examine the relationship between patient/family engagement in goal planning, satisfaction with the goal setting process and associated goal attainment and functional gains during rehabilitation. Method: A prospective cohort analysis of consecutively completed episodes for patients discharged over a 1-year period (January-December 2013) in a specialist neurological rehabilitation service in the UK. Participants were adults (n=83) with neurological disabilities (mean±SD age: 42.8 ±15.0 years; programme length: 98 ± 47 days; male to female ratio: 69:31; diagnosis: brain injury (n=75, 90%), spinal cord injury (n=5, 6%), other neurological conditions (n=3, 4%)). The measures used were sixpoint visual analogue scales to rate goal engagement and goal satisfaction, Goal Attainment Scaling (GAS) and the UK Functional Assessment Measure (UK FIM+FAM). Results: Significant improvements were seen between admission and discharge for patient goal engagement (Mann-Whitney z=-2.2, p=0.027) and satisfaction (z=-2.2, p=0.031). Significant correlations were seen between goal engagement and goal satisfaction for patients on admission (Spearman’s rho 0.41, p=0.03) and for their families on discharge (rho 0.82, p<0.001). Patients’ goal engagement by discharge was strongly correlated with GAS achieved T-scores (rho 0.54, p<0.001) and with functional gain (change in FIM+FAM-Motor subscale rho 0.46, p<0.001). Conclusions: Active involvement of patients and their families in meaningful goal planning is an important component of rehabilitation that is associated with improved goal attainment and better functional outcomes.
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Research
210 International Journal of Therapy and Rehabilitation, May 2015, Vol 22, No 5
© 2015 MA Healthcare Ltd
Research
Patient engagement
and satisfaction with goal
planning: Impact on outcome
from rehabilitation
Aim: To examine the relationship between patient/family engagement in goal planning, satisfaction with
the goal setting process and associated goal attainment and functional gains during rehabilitation.
Method: A prospective cohort analysis of consecutively completed episodes for patients discharged
over a 1-year period (January–December 2013) in a specialist neurological rehabilitation service in
theUK. Participants were adults (n=83) with neurological disabilities (mean±SD age: 42.8 ±15.0years;
programme length: 98 ± 47 days; male to female ratio: 69 :31; diagnosis: brain injury (n=75, 90%),
spinal cord injury (n=5, 6%), other neurological conditions (n=3, 4%)). The measures used were six-
point visual analogue scales to rate goal engagement and goal satisfaction, Goal Attainment Scaling
(GAS) and the UK Functional Assessment Measure (UK FIM+FAM).
Results: Signicant improvements were seen between admission and discharge for patient goal
engagement (Mann-Whitney z=–2.2, p=0.027) and satisfaction (z=–2.2, p=0.031). Signicant
correlations were seen between goal engagement and goal satisfaction for patients on admission
(Spearman’s rho 0.41, p=0.03) and for their families on discharge (rho 0.82, p<0.001). Patients’ goal
engagement by discharge was strongly correlated with GAS achieved T-scores (rho 0.54, p<0.001) and
with functional gain (change in FIM+FAM-Motor subscale rho 0.46, p<0.001).
Conclusions: Active involvement of patients and their families in meaningful goal planning is an
important component of rehabilitation that is associated with improved goal attainment and better
functional outcomes.
Key words: Rehabilitation Goals Goal planning Engagement Patient satisfaction
Submitted 8 January 2015; accepted for publication following double-blind peer review 25 March 2015
Lynne Turner-Stokes, Hilary Rose, Stephen Ashford, Barbara Singer
Goal planning is integral to the proc-
ess of rehabilitation and is often
described as the ‘cornerstone’ of
effective rehabilitation practice
(Wade, 1998; Levack et al, 2006a). There is now
a substantial body of literature, including several
systematic reviews, providing evidence for the
effectiveness of goal planning in enhancing self-
efcacy, motivation, adherence to rehabilitation
and goal-specic performance (Hurn et al, 2006;
Levack et al, 2006b; Sugavanam et al, 2013).
However, systematic goal planning poses
challenges for both patients and their treating
teams. While patients and their families aspire to
longer-term aims or ‘life goals’ (often anticipating
a full recovery), the treating team is usually
focused on the shorter-term objectives that are
achievable within the context of a time-limited
rehabilitation programme. Moreover, their clinical
experience may lead them to expect more modest
aspirations, even for the longer-term. To avoid
difcult conversations and lengthy negotiations
to achieve a ‘realistic’ set of goals, the team will
sometimes exclude patients/families altogether
from the goal planning process (Levack et al,
2009; Sugavanam et al, 2013), especially where
patients have cognitive and/or communicative
problems (Bergquist and Jacket, 1993).
Common sense tells us that patients will
engage most readily in rehabilitation directed
towards goals that are important to them (Wade,
2009), and there is evidence that inclusion of
patients and/or their families in goal planning
leads to improved functional outcomes (Williams
and Steig, 1987; Medley and Powell, 2010;
Dalton et al, 2012; Danzl et al, 2012). Ideally,
therefore, goal planning should form part of an
educational process in which patients and their
families are engaged not only in setting goals
for rehabilitation, but in taking responsibility for
monitoring, achieving and re-setting those goals
along the journey of their recovery.
Lynne Turner-Stokes,
Herbert Dunhill Professor
of Rehabilitation,
Department of Palliative
Care, Policy and
Rehabilitation, Cicely
Saunders Institute, King’s
College London, UK
and Director, Regional
Rehabilitation Unit,
Northwick Park Hospital,
Harrow, Middlesex, UK;
Hilary Rose,
Head of therapy services,
Regional Rehabilitation
Unit, Northwick Park
Hospital, Harrow,
Middlesex, UK;
Stephen Ashford,
Clinical lecturer and
consultant physiotherapist,
Department of Palliative
Care, Policy and
Rehabilitation, Cicely
Saunders Institute, King’s
College London, UK and
Regional Rehabilitation
Unit, Northwick Park
Hospital, Harrow,
Middlesex, UK;
Barbara J Singer,
Professor, Centre for
Musculoskeletal Studies,
School of Surgery,
University of Western
Australia, Perth, Australia.
Correspondence to:
Lynne Turner-Stokes
E-mail:
Lynne.turner-stokes@
dial.pipex.com
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International Journal of Therapy and Rehabilitation, May 2015, Vol 22, No 5 211
© 2015 MA Healthcare Ltd
Patients are involved except where severe cog-
nitive/communicative deficits preclude this.
A key family member or main carer acts as
the patient advocate in such cases or is also
involved alongside the patient
One to six key ‘personal goal-objectives’ for
the programme are identified and agreed on
by the patient (and/or family carer) and their
treating team. Each goal-objective is rated for
importance by the patient and/or family on a
scale of 1 (fairly) to 3 (very important)
A specific, measurable, achievable, realistic
and timed (SMART) goal statement is drawn
up to describe the expected level of achieve-
ment for each goal-objective
Short-term staged goals towards the identied
key goal-objectives are set and reviewed at
fortnightly intervals throughout the programme
to determine whether the patient is on track
Rating of goal attainment against the key
SMART goal-objectives is undertaken together
with the patient and/or family in a review meet-
ing during the nal week of the programme
Attainment for each goal-objective is rated on
a six-point verbal scale and converted to a ve-
point numerical scale (ranging from –2 to +2)
(Kiresuk and Sherman, 1968). An overall GAS
T-score is calculated, including the weighting
for importance of each goal-objective.
Engagement and satisfaction with goal planning
Engagement and satisfaction with goal planning,
are each recorded on a scale of 0–5. Goal
engagement of the patient and/or family is rated
by the treating team (Appendices 1 and2), while
goal satisfaction is rated by the patient and/or
family member (Appendix 3).
Routine recording of these parameters was
introduced in the unit from January 2013. In
the rst 6 months of data collection (period 1),
goal engagement and satisfaction were rated at
discharge only, as part of the goal review meet-
ing. We were subsequently interested to deter-
mine whether these parameters improved during
the course of the programme. Consequently,
during the second 6 months of data collection
(period 2), goal engagement and satisfaction
were also collected at an early stage in the pro-
gramme—approximately 2 weeks after initial
goal setting (the minimum time necessary to be
able to record the level of patient engagement).
As the unit treats a substantial number of
profoundly impaired patients (including those
in vegetative and minimally conscious states),
it was anticipated that a significant proportion
of patients would be unable to engage in goal
planning throughout their programme—patient
Through ongoing dialogue between the patient
and team, the negotiation of shared goals that
are not only realistic but also well-aligned to the
patients’ own priorities for rehabilitation should
lead to increased satisfaction with the overall
outcome of the programme. To date, however,
there has been no systematic attempt to measure
the level of patients’ engagement in goal man-
agement, nor their satisfaction with the goals, as
part of the routine goal planning process.
The GAS-Light approach to Goal Attainment
Scaling (GAS) (Turner-Stokes et al, 2009) is a
simplied approach designed for use in routine
clinical practice. Importantly, this is more
than just an outcome measurement tool—it
facilitates the negotiation of agreed goals and
realistic expectations, and also supports team
communication and reection on goal attainment
as part of practice-based learning (Turner-
Stokes, 2009). A recent renement to the GAS-
Light system is the addition of scales to record
the extent of the patient’s engagement in and
satisfaction with the process of goal planning.
This article presents the rst application of the
goal engagement and goal satisfaction scales in a
cohort undergoing specialist neurorehabilitation.
We examined the association between goal
engagement and goal satisfaction for patients
(and/or their family carer where relevant) and
explored the relationship between these measures
and outcomes from the rehabilitation programme,
including goal attainment and functional gain.
METHODS
Design and setting
A prospective cohort analysis of routinely-
gathered data from an inpatient tertiary specialist
rehabilitation service for younger adult patients
with complex neurological disabilities in the UK.
Completed episodes for patients discharged over
a 1-year period (January–December 2013) were
included if a rating of goal engagement and/or
goal satisfaction of the patient and/or family with
goal planning had been recorded.
Measurements
Goal planning and rating of goal attainment
Goal planning and the rating of goal attainment
is part of established clinical practice in this
unit. Details of team training and the GAS-
Light method of application are described
elsewhere (Turner-Stokes, 2009; Turner-Stokes
et al, 2009). In brief:
Goal setting is undertaken within the first
10 days of the rehabilitation programme.
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212 International Journal of Therapy and Rehabilitation, May 2015, Vol 22, No 5
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goal engagement score of 0—and it would not
be possible to record goal satisfaction. Similarly,
family goal engagement and satisfaction was
only recorded where a family member/main
carer was closely involved in the rehabilitation
programme. The unit serves a wide catchment
area and families often have to travel considerable
distances. Many only visit during weekends
or 1–2 evenings per week, which limits their
opportunity for involvement. Therefore, it was not
expected that all parameters of goal engagement
and satisfaction would be recorded on all patients.
Functional independence
Functional independence was measured using
the UK Functional Assessment Measure (UK
FIM+FAM) (Turner-Stokes et al, 1999) as part
of the unit’s routine outcome reporting to the
UK Rehabilitation Outcomes Collaborative
(UKROC) national clinical dataset.
Data handling and analysis
Data were entered into a spreadsheet (Microsoft
Excel) and transferred to SPSS version 21. As the
scales generate ordinal data, non-parametric tests
were applied throughout. Signicant differences
between admission and discharge were assessed
using Wilcoxon signed-rank tests. Differences
between the patients providing data in periods
1 and 2 were tested using chi-squared tests for
categorical (demographic) data and Mann–
Whitney tests for ordinal data. Correlations
between the various measures were tested using
Spearman’s (rho) correlations.
For the reasons given above, missing data
were expected. No data were imputed. Analysis
was therefore undertaken on a pair-wise basis,
depending on the sample available.
RESULTS
From a total of 91 patients discharged during the
evaluation period, 83 (91%) patients had data on
goal engagement and/or satisfaction and were
included in the analysis. Participants had a mean
age of 42.8 years (SD: 15.0 years) and the male
to female ratio was 69:31. Seventy-five (90%)
patients had acquired brain injury, of which
45 cases (60%) were due to stroke, 21 (28%)
trauma and 9 (12%) other causes. Five (6%)
patients had spinal cord injury and the remaining
3 (4%) patients had other neurological conditions
(e.g. Guillain–Barré syndrome, multiple sclerosis).
The mean length of stay in the programme
was 98 days (SD: 91, range 17–288). During
period1, 36 cases were recorded and in period 2
a further 47 cases were included. No signicant
differences were seen either in demographics or
any of the measurement parameters between the
cohorts represented in period 1 and period 2, so
the data were analysed together.
Approximately one third of patients (n=26,
32%) had catastrophic brain injury and remained
unable to engage in goal planning at any level
throughout their programme. Of these, goal
engagement was recorded for a close family
member in 16 (61%) patients. A further four
patients who were able to engage in goal plan-
ning, but for whom the family role was deemed
particularly critical, had recordings for both
patient and family goal engagement. Table 1
summarises the level of goal engagement and
goal satisfaction at the early stage of the pro-
gramme and at discharge. Signicant improve-
ments were seen between admission and
discharge for patient goal engagement (Mann–
Whitney z =–2.2, p=0.027) and satisfaction
(z =–2.2, p=0.031). Although family members
showed a similar trend, the numbers were very
small and changes seen were non-signicant.
Table 2 shows the correlations between goal
engagement and goal satisfaction for patients
and their families, and the relationship of these
parameters with goal attainment and functional
gain. The statistical signicance of correlations
was affected by the number of data pairs and
correlations with early-stage family goal engage-
ment and satisfaction were not computed due to
the small numbers. As may be expected, patient
goal engagement was strongly correlated with
cognitive ability (UK FIM+FAM cognitive sub-
scale) both early in the programme (rho 0.64,
p<0.001) and at discharge (rho 0.83, p<0.001).
Early-stage goal engagement by patients was
strongly associated with goal satisfaction at
that stage and also with goal engagement (but
not goal satisfaction) at discharge. It was also
significantly correlated with goal attainment
and functional motor (but not cognitive) gains
at discharge. Early-stage patient satisfaction
with goals was strongly associated with goal
satisfaction at discharge, both on the part
of patients and their families, but was not
signicantly associated with goal attainment or
functional gain (Table 2).
Patient goal engagement at discharge was
strongly associated with both goal attainment
and functional motor gain, and a weaker but sig-
nificant relationship was also seen with gains
in cognitive function. Family goal engagement
at discharge was strongly associated with their
goal satisfaction and both were weakly correlated
with goal achievement.
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International Journal of Therapy and Rehabilitation, May 2015, Vol 22, No 5 213
© 2015 MA Healthcare Ltd
Table 1. Goal engagement and satisfaction, with goal attainment and functional change on admission and discharge
Parameter
Early stage* Discharge Change Wilcoxon signed-rank tests
n Median (IQR) nMedian (IQR) n z Signicance
Goal engagement
Patient engagement 44 2 (0–3) 81 2 (0–3) 42 Increased n=12
Decreased n=4
Unchanged n=26
–2.2 0.027
Family engagement 11 3 (2–4) 17 2 (2–3) 9 Increased n=3
Decreased n=2
Unchanged n=4
–0.1 0.89
Goal satisfaction
Patient satisfaction 31 3 (1–4) 55 4 (3–5) 27 Increased n=8
Decreased n=4
Unchanged n=15
–2.2 0.031
Family satisfaction 23 4 (3–4) 26 4 (3–4) 18 Increased n=4
Decreased n=2
Unchanged n=12
–1.1 0.29
Goal attainment Admission Discharge Change score
GAS T-score 82 31.9 (28.4–35.5) 78 50 (45.4–56.6) 78 17.8 (13.7–22.1) –7.5 <0.001
Functional gain
UK FIM+FAM Motor score 83 38 (17–70) 83 83 20 (2–36) –7.2 <0.001
UK FIM+FAM Cognitive score 83 61 (22–77) 83 83 10 (1–20) –6.8 <0.001
*’Early stage’ reects engagement/satisfaction with goals within approximately 2 weeks of goal setting, recorded during period 2 only
GAS: Goal Attainment Scale; IQR: interquartile range; UK FIM+FAM: UK Functional Assessment Measure
(either from an early stage or over the course of
their programme) showed significantly better
outcomes, in terms of both goal attainment and
functional gains, than those who were unable to
engage. In the case of the latter group, family goal
engagement and satisfaction were associated with
goal attainment (the goals largely having been set
with the family at the outset) but, unsurprisingly,
were not associated with functional gain in this
profoundly impaired subgroup of patients.
DISCUSSION
This study represents the rst application of the
goal engagement and goal satisfaction scales within
the GAS-Light system, applied in routine clinical
practice in a specialist neurorehabilitation setting.
As would be expected, goal engagement was
substantially dependent on the level of cognitive
function. However, in general, patients who were
able to engage in their goal planning process
Table 2. Spearman’s rank correlations between parameters of goal engagement and satisfaction at discharge, with goal attainment
and functional gain
Patient early stage Patient on discharge Family on discharge
Engagement Satisfaction Engagement Satisfaction Engagement Satisfaction
Patient early stage
Goal engagement
Goal satisfaction 0.41* (n=30)
Patient on discharge
Goal engagement
Goal satisfaction
0.81 (n=42)
0.26 (n=30)
0.30 (n=30)
0.51 (n=27) 0.25 (n=55)
Family on discharge
Goal engagement
Goal satisfaction
0.16 (n=9)
0.23 (n=18)
0.64 (n=5)
0.92 (n=11)
0.14 (n=17)
0.26 (n=26)
0.58 (n=6)
0.89 (n=16) 0.82 (n=13)
Goal attainment
GAS T-score 0.33* (n=41) 0.24 (n=29) 0.54 (n=76) 0.26 (n=53) 0.36 (n=16) 0.45* (n=24)
Functional gain: Change in:
UK FIM+FAM motor score
UK FIM+FAM cognitive score
0.37 (n=44)
0.05 (n=44)
0.16 (n=31)
0.13 (n=31)
0.46 (n=81)
0.23* (n=81)
0.22 (n=55)
0.05 (n=55)
0.20 (n=17)
0.12 (n=17)
0.27 (n=26)
0. 30 (n=26)
Two-tailed signicance: *p<0.05 p<0.01 p<0.001
GAS: Goal Attainment Scale; UK FIM+FAM: UK Functional Assessment Measure
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214 International Journal of Therapy and Rehabilitation, May 2015, Vol 22, No 5
© 2015 MA Healthcare Ltd
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Although the association between goal
en ga gem ent and fu nctio nal gain doe s not
conrm causation, it adds to the growing body
of evidence to support not only engaging
patients and their families in goal setting, but
also the provision of training in self-regulation
and goal management as an integral part of their
rehabilitation programme to encourage patients
and their families to take responsibility for
monitoring, achieving and re-setting those goals
along the journey towards recovery (McPherson
et al, 2009; Liu and Chan, 2014).
Some of the published evaluations have
highlighted that, while self-regulation approaches
are feasible, they can be time-intensive and
difcult in patients who have cognitive and/or
communication difficulties (McPherson et al,
2009). In this study, despite the trend towards
improved goal engagement over the course of
the programme, 26 out of 43 (60%) patients did
not change in this respect. This could reect the
limited learning ability of our severely impaired
population, or alternatively the lack of a formal
component of systematic self-regulation to the
rehabilitation offered during this period.
Limitations
This study has a number of limitations. For
reasons explained above, we did not expect
to collect all parameters of goal engagement
and goal satisfaction for every patient and their
family during the study period. In addition,
data collection covered the period during
which the scales were rst introduced as part
of routine practice. Initially, goal engagement
and satisfaction were only gathered on
discharge so that change in these parameters
could only be evaluated during period 2,
when we started to collect data in the early
stage as well. Missing data were therefore
expected, but may have led to a type II error
in some of our analyses where numbers
were small, especially in the evaluation of
family goal engagement and satisfaction.
The findings therefore need to be confirmed
in a larger sample and further systematic
data collection is ongoing, alongside a more
concerted approach to include goal management
training as a formal part of our programme.
Patients and their families are likely to engage more readily in goal setting if
they are satised that the agreed goals match their priorities
In this study, patient engagement was strongly correlated with goal satisfaction
and associated with goal attainment and functional gains from rehabilitation
Measurement of these parameters should be an integral part of goal setting
and should form a focus for rehabilitation in their own right.
KEY POINTS
This is a scale to record the level of engagement
of a patient in their own goal setting. It takes
into account a number of factors related to goal
setting behaviour, including:
Their cognitive ability to be aware of
themselves, their situation and their
environment
Their communicative ability to articulate their
priorities and frame those in specic goals
Their adjustment to limitations and level of
realistic expectation for the future
Their behavioural approach to rehabilitation,
including self-monitoring, motivation and ability
to organise themselves.
The simple scale above does not attempt to
tease these out. If the patient is at different level
with respect to these factors—e.g. they have the
cognitive ability to understand, but cannot or will
not accept the concept of goal negotiation—the
lower score is used.
Excellent engagement
Fully independent in goal monitoring
and setting their own goals
Very good engagement
Patient takes most of responsibilty for
monitoring and re-setting goals
Good engagement
But requires active support
Patient and team take 50/50 responsibility
Moderate engagement
Patient engages to some degree, but team
takes most of responsibility (>50%) for
monitoring and re-setting goals
Minimal engagement
Patient indicates general goal area, but cannot
engage in goal setting to any meaningful level
Unable
Cannot engage in goal setting at any level
Patient level of engagement in goal setting
(as judged by team)
Appendix 1. Goal engagement scales (patient). © Prof L Turner-Stokes, Northwick Park Hospital.
Reproduced with permission
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International Journal of Therapy and Rehabilitation, May 2015, Vol 22, No 5 215
© 2015 MA Healthcare Ltd
CONCLUSIONS
Active involvement of patients and their
families in meaningful goal planning is a critical
component of rehabilitation, but until now there
has been no simple way to measure this. The
patient/family engagement and goal satisfaction
scales provide a practical approach to evaluation
of these important person-centred aspects of goal
setting. While cause and effect have yet to be
proven, our ndings provide supportive evidence
that engagement and satisfaction with the
agreed goals are associated with improved goal
attainment and better functional outcomes. IJTR
The goal engagement and goal satisfaction
scales presented in this study are freely available
from the authors or from this website:
www.kcl.ac.uk/lsm/research/divisions/cicelysaun-
ders/attachments/Tools-GAS-Engagement-Scales.pdf
Acknowledgements: The authors are grateful to
all the patients, clinical and administrative staff
on the Regional Rehabilitation Unit who were
involved in gathering and collation of these data.
We are especially grateful to Heather Williams
and Keith Sephton for providing the UKROC data.
Declaration of interest: Outcome measurement is
a specic research interest of our centre. The UK
This is a scale to record the level of engagement
of a patient’s family in setting goals for the patient
when the patient is unable. It takes into account
a number of factors related to goal-setting
behaviour, including:
Their understanding of the patient’s limitations,
their adjustment to this, and their level of
realistic expectation for the future
Their ability to articulate the priorities,
advocating for the patient and framing those
priorities in specic goals
Their approach to rehabilitation, including
monitoring the goals and re-setting goals as
appropriate or setting process goals (i.e. linked
to care plans or discharge planning as required).
The simple scale above does not attempt to
tease these out. If the family is at different level
with respect to these factors—e.g. they have
the pockets of insight/ability to understand,
but cannot/ will not accept the concept of goal
negotiation, the lower score is used.
Excellent engagement
Fully able to monitor the patient’s goals
and set the patients goals
Very good engagement
Family take most of responsibility for
monitoring and re-setting goals
Good engagement
But require active support
Patient and team take 50/50 responsibility
Moderate engagement
Family engage to some degree, but team
takes most of responsibility (>50%) for
monitoring and re-setting goals
Minimal engagement
Family indicate general goal area, but cannot
engage in goal setting to any meaningful level
Unable
Cannot or will not engage in goal setting at
any level
Family level of engagement in goal setting
(as judged by team)
Appendix 2. Goal engagement scales (family). © Prof L Turner-Stokes, Northwick Park Hospital.
Reproduced with permission
FIM+FAM and the GAS-Light were both devel-
oped through this department, but are dissemi-
nated free of charge to trained users. None of the
authors have any personal nancial interests in
the work undertaken or the ndings reported.
Funding sources: This manuscript presents
independent research funded by the National
Institute for Health Research (NIHR) under its
Programme Grants for Applied Research fund-
ing scheme (RP-PG-0407-10185). The views
expressed in this article are those of the authors
and not necessarily those of the NHS, the NIHR
or the Department of Health. Financial support
for the preparation of this manuscript was also
provided by the Dunhill Medical Trust.
Ethics permission: Ethics permission to use
our clinical data for the purposes of research
and evaluation was provided by the NRES
Committee-Harrow (ref 04/Q0405/47)
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216 International Journal of Therapy and Rehabilitation, May 2015, Vol 22, No 5
© 2015 MA Healthcare Ltd
Excellent
My goals matched all my key priorities for rehab and were entirely my
own choice
Very good
My goals matched my main priorities for rehab and I was pretty happy
with my agreed goal-set
Good
My goals met most of my priorities for rehab and I agreed with some of
them
Moderate
My goals met some of my priorities for rehab and I agreed with some
of them
Poor
My goals were largely irrelevant to me and I disagree with most of them
None
My goals were completely irrelevant and I did not agree with any them
or, what goals?
This is a scale to record patient’s satisfaction with goal setting. It takes into
account a number of factors related to goals:
How well the goals matched their priorities for rehab
The extent to which they agreed with the goals
The extent of choice in goal areas
The extent to which they felt involved with/in charge of the goal setting
process
The simple scale above does not attempt to tease these out. If the patient is
at different level with respect to these factors—e.g. they had a wide choice of
goals but did not agree with any of them—the lower score is used.
Patient satisfaction with the goal setting process
(as judged by patient/family)
Appendix 3. Goal engagement and goal satisfaction scales. © Prof L
Turner-Stokes, Northwick Park Hospital. Reproduced with permission
general method of evaluating comprehensive mental health
programmes. Community Ment Health J 4(6): 443–53
Levack WM, Dean SG, Siegert RJ, McPherson KM (2006a)
Purposes and mechanisms of goal planning in rehabilita-
tion: The need for a critical distinction. Disabil Rehabil
28(12): 741–9
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... Furthermore, by referring to each item's scores, it became possible to understand, in detail, the categories that required motivational care. The category "goal setting," which the items 1,2,3, and 4 referred to, have been reported to be related to the improvement of daily living activities [42,43]. "Pain" in Item 14, which is included in the category "physical condition and cognitive function", has been reported to have a negative effect on FIM improvement [44]. ...
Article
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Objective This study aimed to develop the Motivation in stroke patients for rehabilitation scale (MORE scale), following the Consensus-based standards for the selection of health measurement instruments (COSMIN). Method Study participants included rehabilitation professionals working at the convalescent rehabilitation hospital and stroke patients admitted to the hospital. The original MORE scale was developed from an item pool, which was created through discussions of nine rehabilitation professionals. After the content validity of the scale was verified using the Delphi method with 61 rehabilitation professionals and 22 stroke patients, the scale’s validity and reliability were examined for 201 stroke patients. The construct validity of the scale was investigated using exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and item response theory analysis. Cronbach’s alpha confirmed its internal consistency. Regarding convergent, discriminant, and criterion validity, Spearman’s rho was calculated between the MORE scale and the Apathy Scale (AS), Self-rating Depression Scale (SDS), and Visual Analogue Scale (VAS), which rates the subjective feelings of motivation. Results Using the Delphi method, 17 items were incorporated into the MORE scale. According to EFA and CFA, a one-factor model was suggested. All MORE scale items demonstrated satisfactory item response, with item slopes ranging from 0.811 to 2.142, and item difficulty parameters ranging from -3.203 to 0.522. Cronbach’s alpha was 0.948. Regarding test-retest reliability, a moderate correlation was found between scores at the beginning and one month after hospitalization (rho = 0.612. p < 0.001). The MORE scale showed significant correlation with AS (rho = -0.536, p < 0.001), SDS (rho = -0.347, p < 0.001), and VAS (rho = 0.536, p < 0.001), confirming the convergent, discriminant, and criterion validity, respectively. Conclusions The MORE scale was verified as a valid and reliable scale for evaluating stroke patients’ motivation for rehabilitation.
... The results of this study are relevant to the development of reporting criteria for clinical trials concerning factors related to service organization (22). This is based on the grounded hypothesis that rehabilitation outcomes may be influenced by factors such as the service location, structure and profile of rehabilitation team, technical resources and other factors related to service organization (6,24,(34)(35)(36)(37)(38). Such factors can be seen as contextual factors in service delivery, which is in line with the comprehensive World Health Organization (WHO) model of functioning and health (39). ...
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Objective: To identify the most important categories of the International Classification of Service Organization in Rehabilitation (ICSO-R 2.0) for a minimum reporting data set. Methods: A 2-step Delphi survey was used. Rehabilitation experts from all world regions including physicians, nurses, neuropsychologists, physiotherapists, and others, were invited to participate. In the first round, all participants were asked to rate the categories and subcategories of the ICSO-R 2.0 with the following criteria: Being relevant for study outcomes; Being distinctive among different rehabilitation settings; Being feasible to use and reported by objective figures or other clear characterization. All categories that were rated relevant, distinctive and feasible by more than 60% of respondents from the first round were included in the second round. Results: The most important and relevant factors for the minimum reporting set in rehabilitation services regarding the provider were: human resources, context, technical resources, quality assurance and management, location of provider, and ownership. Regarding the service delivery, the most important and relevant factors were: target group, rehabilitation team, aspect of time and intensity, setting, location of service delivery, modes of referral, facility and reporting and documentation. Conclusion: Several categories were identified, and reduction in these through discussions and iterative voting at workshops and consensus conferences is needed before finalizing the reporting set.
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Identifying and synthesizing recent empirical research on goal setting among adults with chronic disease is the focus of this article. The article has two phases: Phase 1, a thematic analysis with machine reading of the data and manual thematic analysis, and Phase 2, a quantitative meta-analysis. Qualitative, quantitative, and mixed-method studies are included in Phase 1 (99 papers). Phase 2 includes only quantitative studies (75 papers). Five main themes are identified: (a) the effect of goal characteristics on health-related outcomes, (b) the effect of goal setting on health-related outcomes, (c) the effect of goal achievement on health-related outcomes, (d) goal alignment between patients and health care service providers, and (e) individual and collaborative goal setting of patients and health care service providers. The meta-analysis reveals considerable evidence of an association between goal setting and health-related outcomes.
Chapter
Neuropathic pain is a complex pain syndrome that results from a lesion or disease of the central or peripheral somatosensory nervous system. Its diagnosis is often missed or delayed, due to the complexity of potential etiologies and varied presentations. Neuropathic pain presents a considerable economic burden to global health systems and is a major disruptor to the quality of life of individual sufferers. The incidence of neuropathic pain is projected to rise in our aging population, which features a high prevalence of chronic comorbidities. A gold-standard treatment protocol for neuropathic pain has yet to be established and the estimation that less than half of individuals suffering from neuropathic pain are engaged in successful first-line pharmacological treatment, suggests that the current management paradigm requires further consideration. Exercise represents a non-invasive, accessible, and well-tolerated component of a multidisciplinary management plan. This chapter provides an update on the existing knowledge and recommendations for exercise as a management strategy for neuropathic pain.
Article
Purpose: Person-centred goal setting with people with brain injury, by interdisciplinary teams has benefits including improved communication between patients, families and clinicians, person-centred care, and improved engagement in rehabilitation. Exploring the experiences of team members who have adopted interdisciplinary, person-centred goal setting may assist in understanding what is needed to implement this complex, core component of rehabilitation practice. This study explored experiences of clinicians working in an extended inpatient brain injury rehabilitation unit about implementing a role-based goal planning approach within an interdisciplinary team. Materials and methods: Semi-structured interviews with 13 clinicians working at the rehabilitation unit explored their experiences about the cognitive participation and collective actions required to carry out the practice, with data analysed using inductive content analysis guided by Normalisation Process Theory. Results: Three primary themes were identified: putting the person at the centre, accepting the mind-shift to participation focused goals and working collaboratively. Conclusions: This study has elucidated some key processes that occurred and were necessary to carry out goal setting. A mind-shift towards holistic, participation-focussed goal setting was described as "unlearning" discipline-specific goal setting. Development and ownership by the team, acceptance of team members and willingness to share, and structured processes and resources were necessary.IMPLICATIONS FOR REHABILITATIONNormalising interdisciplinary role-based goal setting in multi-professional teams requires a mind-shift away from traditional, discipline-specific goal setting.Implementation of interdisciplinary, collaborative team goal setting within health service settings requires collective actions including collaborative working by team members, structured processes including organised time for collaborative team and family meetings, practical resources and training to support processes.Clinicians perceived the goal setting approach to put the person at the centre resulting in a deep understanding of the person, shared understanding, and motivation for rehabilitation.
Article
Therapieziele zu vereinbaren gehört zum ergotherapeutischen Alltag. Manche formulieren Ziele SMART, andere unterscheiden Nah- und Fernziele. Es gibt aber auch eine ergotherapiespezifische Möglichkeit, Ziele zu vereinbaren: die COAST-Methode. Sie ist derzeit die einzige Methode, die zentral auf Betätigung ausgerichtet ist.
Article
Objective Develop and test a person-centred goal-setting package for discharge care planning in acute and rehabilitation stroke units. Methods A multidisciplinary, expert working group (n = 15), and consumer group (n = 4) was convened. A multistage iterative approach was used to develop and test the package. Stages included: (i) contextual understanding, (ii) package development, and (iii) clinician training and field-testing in acute and rehabilitation settings. Observational field notes were taken and clinician's perspectives captured using semi-structured focus groups post-testing. Results The final package included a 34-item menu aligned with a manual containing: guideline summaries; common goals; goal metrics based on the SMART Goal Evaluation Method (SMART-GEM); evidence-based strategies; and worked examples. Twenty-three clinicians attended training. Clinician observations (n = 5) indicated that: the package could be incorporated into practice; a range of person-centred goals were set; and opportunities provided to raise additional issues. Clinician feedback (n = 8) suggested the package was useful and facilitated person-centred goal-setting. Enablers included potential for incorporation into existing processes and beliefs that it promoted person-centred care. Barriers included additional time. Conclusion The package demonstrated potential to facilitate comprehensive person-centred goal-setting for patients with stroke. Innovation We developed an innovative approach to support structured person-centred goal setting in clinical and research settings.
Article
Objective This systematic review aims to examine 1) what components are used in current person-centered goal setting interventions for adults with health conditions in rehabilitation and 2) the extent to which the engagement of people in their rehabilitation goal setting is encouraged. Data Sources PubMed/MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health Literature, SCOPUS, and Web of Science from inception to November 2020. Study Selection Primary inclusion criteria were peer-reviewed articles that evaluated person-centered goal setting interventions for adults with health conditions in rehabilitation. Two independent reviewers screened 28,294 records, and 22 articles met inclusion criteria. Data Extraction Two reviewers independently completed data extraction and quality assessment using the Physiotherapy Evidence Database (PEDRo) scale based on the original authors’ descriptions, reports, and protocol publications. Any discrepancies were resolved by consensus or in consultation with another senior reviewer. Data Synthesis Using narrative synthesis, we found that current person-centered goal setting has variability in their inclusion of intervention components. A considerable number of components are under-implemented in current practice, with formulation of coping plan and follow-up being most commonly left out. The active engagement of people does appear to be promoted within the components that are included in the interventions. Nine studies were high-quality defined as a total PEDro scale score of 6 or above. Conclusions Although current person-centered goal setting encourages the active engagement of people, many of these interventions lack components considered important for supporting goal achievement and optimal outcomes. Future practice may be improved by incorporating a comprehensive set of goal setting components and encouraging the active engagement of people throughout the entire goal setting process. Together, these practices may facilitate the achievement of meaningful rehabilitation goals and improve rehabilitation outcomes for adults with health conditions.
Article
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A mental health enterprise may be described by either (a) rather general philosophical total mental health goals, or (b) highly diverse and individualized patient-therapist goals. Goals a. have not provided a workable framework for program evaluation. This paper proposes that evaluation be done in the framework of goals b. by setting up, before treatment, a measurable scale for each patient-therapist goal, and specifying, for each patient, a transformation of his overall goal attainment into a standardized T-score. This method, together with random assignment of patients to treatment modes, was devised to permit comparison of treatment modes within a program, but it also provides a good basis for a judgmental evaluation of the total program.
Article
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A primary goal of neurorehabilitation is to guide recovery of functional skills after injury through evidence-based interventions that operate to manipulate the sensorimotor environment of the client. While choice of intervention is an important decision for clinicians, we contend it is only one part of producing optimal activity-dependent neuroplastic changes. A key variable in the rehabilitation equation is engagement. Applying principles of engagement may yield greater neuroplastic changes and functional outcomes for clients. We review the principles of neuroplasticity and engagement and their potential linkage through concepts of attention and motivation and strategies such as mental practice and enriched environments. Clinical applications and challenges for enhancing engagement during rehabilitation are presented. Engagement strategies, such as building trust and rapport, motivational interviewing, enhancing the client education process, and interventions that empower clients, are reviewed. Well-controlled research is needed to test our theoretical framework and suggested outcomes. Clinicians may enhance engagement by investing time and energy in the growth and development of the therapeutic relationship with clients, as this is paramount to maintaining clients' investment in continuing therapy and also may act as a driver of neuroplastic changes.
Article
Full-text available
The benefits of rehabilitation following acquired brain injury (ABI) are all too often disrupted by a lack of engagement in the process, variously attributed to cognitive, emotional and neurobehavioural sequelae, and prominently to impaired self-awareness of deficits. Motivational Interviewing (MI) has been widely applied to address treatment adherence in health settings, including a small but emerging evidence base in brain injury contexts. A conceptual review of the literature is offered, examining the interplay of neurological and psychosocial determinants of engagement difficulties after ABI, and discussing the possibilities and limitations of MI as a therapeutic strategy to enhance motivation. The theoretical bases of MI are outlined, focusing particularly on the transtheoretical stages of change model and self-determination theory. The converging evidence suggests that the guiding philosophy and principles of MI - characterised by non-confrontation, collaboration and self-efficacy - might help to foster readiness for participation in rehabilitation. A dynamic motivational model of engagement is presented, identifying MI's potential contribution in three key areas: firstly, to set the stage for therapeutic alliance and case formulation; secondly, to facilitate acceptance of deficits and realistic goal-setting; and thirdly, to promote constructive engagement in the range of clinical interventions that comprise a holistic neurorehabilitation programme.
Article
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To compare goal attainment scaling (GAS) and standardized measures in evaluation of person-centred outcomes in neurorehabilitation. A prospective cohort analysis from a tertiary inpatient neuro-rehabilitation service for younger adults with complex neurological disability. Consecutive patients (n = 164) admitted for rehabilitation following acquired brain injury (any cause) over 3 years. Mean age 44.8 (standard deviation 14.4) years. Diagnosis: 66% strokes, 18% trauma, 16% other. Male:female ratio 102:62. GAS-rated achievement of 1-6 patient-selected goals was compared with the Functional Assessment Measure (UK FIM+FAM), and Barthel Index (BI), rated on admission and discharge. Personal goals were mapped retrospectively to the FIM+FAM and International Classification of Functioning, Disability and Health (ICF). Median (interquartile range; IQR) GAS T-scores were 50.0 (44.2-51.8) and moderately correlated with changes in FIM+FAM and BI (both rho 0.38 (p < 0.001)). Standardized response means were 2.2, 1.6 and 1.4 for GAS, FIM+FAM and BI, respectively. Of 667 personal goals set, 495 (74%) were fully achieved. Although 413 (62%) goals were reflected by changes in FIM+FAM, over one-third of goals were set in other areas. Conclusion: GAS appeared to be more responsive, and captured gains beyond the FIM+FAM, thus providing added value as an adjunct to outcome measurement in patients with complex disability.
Article
To test the efficacy of self-regulation for promoting task performance and motor and cognitive functions. Pilot randomized controlled trial. An in-patient rehabilitation stroke unit. Participants: Forty-four acute post-stroke in-patients aged ≥60 years after a cerebral infarction. The patients were randomly assigned to the self-regulation (n = 24) or functional rehabilitation (control) (n = 20) intervention. The self-regulation intervention consisted of 1-week of therapist-supervised practices of daily tasks using self-reflection of one's own performance (5 one-hour sessions). Patients in the control intervention practiced the same daily tasks with a therapist's demonstration and guidance. Performance of tasks including household and monetary transaction tasks; Functional Independence Measure; Fugl-Meyer Assessment; Color Trails Test. The self-regulation group showed significant improvement in all tasks (median diff. = 1.0 to 2.0; effect size (r) = .74 to .89) versus none (median diff. = 0 to 0.5) in the control group. Results of the Functional Independence Measure (P<.001, r = .87 in motor subscale; P<.001, r = .49 in cognitive subscale), Fugl-Meyer Assessment (P<.001, r = .84 and .63) and Color Trails Test (P=.002, r = .72) of the self-regulation group improved. The self-regulation group outperformed their control counterparts in 4 of the 5 tasks (median diff. = 1.0; r = .30 to .52)) and in the Functional Independence Measure motor subscale (P=.002, r = .47), but not in the cognitive subscale, motor and cognitive functions. Self-regulation appears useful for improving task performance that demands both motor and cognitive abilities by promoting information processing and active learning.
Article
Background and aims: The aim of this study was to develop and evaluate the UK version of the Functional Assessment Measure (UK FIM+FAM). Design: Before and after evaluation of inter-rater reliability. Development: Ten ‘troublesome’ items in the original FIM+FAM were identified as being particularly difficult to score reliably. Revised decision trees were developed and tested for these items over a period of two years to produce the UK FIM+FAM. Evaluation: A multicentre study was undertaken to test agreement between raters for the UK FIM+FAM, in comparison with the original version, by assessing accuracy of scoring for standard vignettes. Methods: Baseline testing of the original FIM+FAM was undertaken at the start of the project in 1995. Thirty-seven rehabilitation professionals (11 teams) each rated the same three sets of vignettes – first individually and then as part of a multidisciplinary team. Accuracy was assessed in relation to the agreed ‘correct’ answers, both for individual and for team scores. Following development of the UK version, the same vignettes (with minimal adaptation to place them in context with the revised version) were rated by 28 individuals (nine teams). Results: Taking all 30 items together, the accuracy for scoring by individuals improved from 74.7% to 77.1% with the UK version, and team scores improved from 83.7% to 86.5%. When the 10 troublesome items were taken together, accuracy of individual raters improved from 69.5% to 74.6% with the UK version (p<0.001), and team scores improved from 78.2% to 84.1% (N/S). For both versions, team ratings were significantly more accurate than individual ratings (p<0.01). Kappa values for team scoring of the troublesome items were all above 0.65 in the UK version. Conclusion: The UK FIM+FAM compares favourably with the original version for scoring accuracy and ease of use, and is now sufficiently well-developed for wider dissemination.
Article
A sample of 180 patients treated at The Boulder Pain Control Center was randomly chosen to participate in Goal Attainment Scaling (GAS). Of these participants, a total of 76 returned for a 6-month follow-up assessment. Data from these patients were used for two studies: (a) a study of the construct validity of the GAS as a treatment outcome measure, and (b) an assessment of treatment efficacy using the GAS. For the first study, Rao's canonical factor analysis was used to judge the construct validity of the GAS scores. There is moderate statistical evidence to show that GAS can add to our understanding of the structure of pain treatment outcome measures. For the second study, a simple comparison of the treatment group (n = 76) with a control group (n = 129) on several functional, verbal, and sociocultural outcome measures showed that GAS participation accounted for 24.7% of the variance in improvement after treatment.
Article
Objective: To systematically integrate and appraise the evidence for effects and experiences of goal setting in stroke rehabilitation. Design: Systematic review of quantitative and qualitative studies. Methods: Relevant databases were searched from start of database to 30 April 2011. Studies of any design employing goal setting, reporting stroke-specific data and evaluating its effects and/ or experiences were included. Results: From a total of 53998 hits, 112 full texts were analysed and 17 studies were included, of which seven evaluated effects while ten explored experiences of goal setting. No eligible randomized controlled trials were identified. Most of the included studies had weak to moderate methodological strengths. The design, methods of goal setting and outcome measures differed, making pooling of results difficult. Goal setting appeared to improve recovery, performance and goal achievement, and positively influenced patients' perceptions of self-care ability and engagement in rehabilitation. However, the actual extent of patient involvement in the goal setting process was not made clear. Patients were often unclear about their role in this process. Professionals reported higher levels of collaboration during goal setting than patients. Patients and professionals differed on how they set goals, types of goals set, and on how they perceived goal attainment. Barriers to goal setting outnumbered the facilitators. Conclusion: Due to the heterogeneity and quality of included studies, no firm conclusions could be made on the effectiveness, feasibility and acceptability of goal setting in stroke rehabilitation. Further rigorous research is required to strengthen the evidence base. Better collaboration and communication between patients and professionals and relevant education are recommended for best practice.
Article
To investigate the effects of patient participation in multidisciplinary goal setting during early inpatient rehabilitation after acquired brain injury. Case controlled retrospective study. Setting: Regional neurological rehabilitation unit. Subjects: One hundred and five patients with acquired brain injury. Numbers of goals set and achieved per patient before and after intervention; Barthel Index and Functional Independence Measure. The intervention resulted in a significant increase in the number of goals set per patient (340 versus 411 total goals, mean per patient 6.3 pre versus 8.05 post, P = 0.008). More patients had multiple goals set within each domain (P = 0.023). There was an increase in the number of patients with sleeping (0 pre, 9 post), continence (3 pre, 17 post) and leisure (15 pre, 35 post) goals set, and leisure goals achieved (60% pre and 68% post, P < 0.001). Correlations between goal achievement and change in activity-related outcome measures (Barthel Index and Functional Independence Measure) also improved with the new goal setting process. The proportion of goals achieved remained similar (60% pre and 63% post intervention), suggesting there was no evidence of inappropriate or unachievable goals set when the patient and family were included. Real-time engagement of brain-injured patients in the goal setting process during early inpatient rehabilitation is achievable, but requires a structured multidisciplinary assessment of need. We found it increases the number of domains in which goals are set and includes functional areas not rated by commonly used global measures of outcome during inpatient rehabilitation.
Article
To determine the acceptability and clinical application of two recently developed goal-setting interventions (Goal Management Training and Identity Oriented Goal Training) in people with traumatic brain injury. A three parallel group, randomized controlled pilot study.Setting: Inpatient and community rehabilitation facilities. Thirty-four people with moderate to severe traumatic brain injury (Goal Management Training, n = 12; Identity Oriented Goal Training, n = 10; usual care, n = 12) and their rehabilitation clinicians. For both Goal Management Training and Identity Oriented Goal Training participants met face to face with their key worker weekly over a period of 6-8 weeks, during which time the key worker worked to engage them in goal setting and goal performance using the strategy prescribed by their group allocation. Usual care was provided to the other participants. Largely qualitative using observation, individual interviews and focus groups. Participants also completed a Goal Attainment Scale at baseline, post intervention and at three months follow-up. Both approaches were acceptable to the majority of participants with many reporting improved mood and goal attainment. Clinicians found working in a different way with patients both challenging and rewarding, with both experimental approaches enhancing a focus on the person's own goals. Identity Oriented Goal Training seemed particularly helpful in engaging people in the goal-setting process while Goal Management Training appeared particularly helpful in providing a structured framework for error prevention in attempting goal performance. These theoretically informed approaches to goal setting showed promise but were time intensive and at times difficult for practitioners to utilize.