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People Factors
Tools for creating goals with patients as a part of therapy

At a glance:
Therapy is more likely to be successful if it is meaningful to the patient and the patient can see how it will make a difference in their lives.

Setting patient-centred functional goals means that the aim of therapy is for the patient to get back to doing activities that are important to them – activities that their injury, illness or disability
disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 has made difficult. This approach is supported by healthcare policies, medical organisations, compensation organisations and research.

This article provides guidelines for setting patient-centred functional goals.
Perspectives:
Employee
This paper was written about hospital-based rehabilitation
rehabilitation
The process of helping a person back to their former abilities and quality of life (or as close as possible) after injury or a medical condition.
 after a problem such as a heart attack, or a major car accident.

The same issues apply in rehabilitation after a work injury. Having a work injury and returning to work can be difficult. The outcome is more likely to be successful if you are motivated. Motivation can be increased by identifying activities you would like to be doing and goals you would like to achieve. These can be personal goals or work goals. Setting goals can help you to see clearly what you are trying to achieve and assist you in getting through difficult periods.
Employer
This article indicates that rehabilitation results are improved when patients are involved in setting goals for recovery that are meaningful for them.

Returning to work is frequently left to the efforts of the individual who is injured. The outcome is more likely to be successful if the person is motivated. Being off work, coping with pain, and not be able to do usual activities is demotivating for most people.

A person's motivation is increased when their goals are meaningful in the context of their lives.

Return to work plans always include goals. Typical goals are increasing the number of hours of work or performing certain duties. Return to work will be more successful if the employee participates actively in developing the return to work plan and setting their own return to work goals.

When discussing return to work duties, try to include goals which will increase the employee's the motivation and sense of job satisfaction. This could be returning to their normal work team or shift, being able to work overtime hours, or returning to specific duties they have enjoyed in the past.
Treater
Setting goals improves rehabilitation outcomes. This paper proposes that rehabilitation is more successful when the goals are set by the patient.

A patient's goals may be based at the workplace, such as getting back to their usual work team and duties. Goals can also be personal, such as returning to dancing, golf, or other leisure activities, or being free from the requirements of a compensation system.
Insurer
Setting goals that provide direction and motivation helps people get back to normal duties sooner. Encourage employees with a work injury to set their own goals, and encourage workplaces to involve employees in developing a return to work plan. A return to work plan that includes patient centred goals is more likely to be successful.
Original Article, Authors & Publication Details:
K. E. Randall and I. R. McEwen (2000).

Writing patient-centered functional goals. Physical Therapy 80(12): 1197.

1Department of Physical Therapy, University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK 73190.
2 Department of Physical Therapy, University of Oklahoma Health Sciences Center.
Background, Study Objectives, How It Was Done:
Today, “health' no longer means simply “not having a disease' but rather “being able to carry out the tasks that are important to you.' During treatment, most patients are more interested in getting back to their old activities than they are in meeting medical definitions of improvement.

"Function' is the ability to do the activities that give a person's life meaning - the activities that are necessary for their physical, psychological
psychological
Refers to a person's perceptions, thought processes, emotions, personality and behaviour. Psychologists can treat mental health problems.
 and social wellbeing. They might be activities related to looking after oneself, or they might be work, or leisure activities.

Setting patient-centred functional goals means that the aim of therapy is to get back to doing these activities when an injury, illness or disability has made them difficult. The goals are described as “patient-centred' because the patient plays a central role in setting them, working together with their physiotherapist and perhaps their family, carer or other significant people in their lives.

An example of a non-functional goal might be “to improve balance and muscle strength' whereas a patient-centred functional goal might be might be “to cook for myself,' or “get back to my normal job' or “to play sport again.' Patient-centred functional goals can focus on the patient's self-care, work or leisure.

Therapy is more likely to be successful if it is meaningful to the patient, and they can see how it will make a difference in their lives. They have more reason to actively participate if they have a worthwhile goal.
Study Findings:
Setting patient-centred functional goals needs to be a “team effort' between the patient and their therapist, sometimes with the input of their family or significant others. For a goal to be truly patient-centred, it needs to be based on the patient's desired outcomes, not what the therapist thinks is “best' for the patient.

The author of this paper recommended that therapists use the following three steps when setting goals with patients:

  1. Find out what the patient wants to get out of therapy
  2. Develop an understanding of the patient's self-care, work and leisure, and the different environments they do things in.
  3. Work together with the patient to set specific goals based on what they want to get out of therapy.
These three steps were then explored in more detail.

Step 1: Finding out what the patient wants to get out of therapy.

This might include asking questions like:

Does this condition stop you from doing activities you want to do? Which activities?
If you were to focus all your energy on one thing for yourself, what would it be?
What activities do you need help with that you'd rather do yourself?
What are your concerns about returning to work, home, school or leisure activities?
Imagine it's 6 months down the road. What would you like to be different?

The patient might have more than one aim in mind. When this happens they should rank which outcomes are the most important. The Canadian Occupational Performance Measure is a tool that helps patients identify and rank their goals before therapy, and measures how well the patients feel these goals have been achieved after therapy. It was designed for occupational therapists, but the authors of this paper found that it could also be used for physiotherapy.

Patients might have an aim that the therapist does not think can be achieved. For example, someone who has completely severed their spinal cord might say “I want to walk again.' At present, walking is not achievable, but the therapist and the patient could look at functional components of this goal – for example by looking at other ways to be mobile and independent.

Step 2: Developing an understanding of the patient's self-care, work and leisure, and the environments they do things in.

This is essential to make sure the goals are relevant to the patient's environment. For example it is not helpful for a patient to learn how to walk on flat hospital floors if they want to return home to a farm with rough ground.

Some questions that might be asked are:

Tell me about yourself
Tell me about your home life. What activities do you do at home? What is your home environment like?
Is there anyone who can help you with the activities you want to do?
Tell me about what you do at work. How do you get to work? Describe your work area.
What do you like to do in your spare time? Where do you do these activities?
Describe a “typical day' for you.

3. Working together with the patient to set specific goals based on what they want to get out of therapy.

Goals need to be specific and measurable and have a timeline. The authors of this paper suggested answering the following questions when setting goals:

Who?

The goal should always focus on the patient, even if they need help to complete an activity.

What?

The goals need to be specific and relate to the patient's overall aims for their therapy.

The author advised avoiding the words “be able to.' (The goal should be “to clean my house' not “to be able to clean my house') This is because a person might be able to do an activity, but not always manage to do it successfully. This is especially important when people have the ability to do an activity, but have trouble with the motivation.

Under what conditions?

It is important to make the goal detailed to ensure that that it is personally relevant for the patient. This might mean specifying when or where the patient wants to do their activity, or how long they want to take to complete a task. The goal might be “to walk down 5 steps (to get out to my back yard)' or “to walk 10m unassisted (because this is the distance to the bathroom)".

How well?

The person might still need assistance to complete their activity, or might not be able to do it perfectly every time. This should be specifically described in their goal, so that the patient can measure when they have achieved their goal. The goal might be “to walk down 5 steps with the help of a hand-rail.'

By when?

This is the target date to achieve the goal. Usually the therapist sets this time-frame based on research, experience and their knowledge of how long injuries usually take to heal or of how this particular patient has progressed in the past. The date might change during treatment.

Patients might not achieve their overall aims in one setting. As they proceed through their treatment, they continue making goals that work towards their overall aim.

For example, a patient's aim after an injury or illness might be “to go home and take care of myself.' Later on during rehabilitation the goal may be “to walk for 15 minutes' or “go back to two hours of work per day.'

The researchers stressed that when therapists are setting goals with their patients they should ask the question: “What difference does it make to the patient if they can do this activity?' A worthwhile goal is one that is important and meaningful to the patient. A patient with a worthwhile goal has more reason to actively participate in their therapy.
Conclusions:
Setting goals is an essential part of therapy. Setting patient-centred functional goals means that the aim of therapy is for the patient to get back to doing the activities that are important to them when their injury, illness or disability has made these activities difficult.

Setting patient-centred functional goals is considered to be the best approach in many areas of healthcare. It is supported by research, health policies, medical organisations and compensation organisations. The authors of this paper believed that therapy is more effective and more meaningful for patients when it is based on patient-centred functional goals.

Setting patient-centred functional goals can change the way therapists and patients communicate with each other. Therapists can spend more time getting to know their patients and finding out about the self-care, work and leisure activities that are important to them.
References:
PubMed Abstract
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