Research

Goal Setting Project

New project to enhance students' goal setting skills   

Setting long and short-term goals for the client with communication disability is a core component of management in speech and language therapy. Alongside other skills (such as information gathering, diagnostic assessment, therapy, and report/ case note writing), goal setting occupies comparatively little of the taught and practised curriculum. Whilst textbooks cover goal setting, the approaches described are traditionally assessment and clinician driven. They tend not cover recent developments such as person-centred planning, and do not address issues of adult ownership and involvement in therapy, family member involvement, and goal setting within multidisciplinary teams.

This 10 month project started in May and will run until the end of March 2010. The purpose is two-fold:

This will improve our teaching of goal setting to students, whether they are learning in the classroom or in clinical placements.

The project has 3 stages:

The project is funded by the Centre for Excellence in Teaching and Learning Clinical and Communication Skills (CETL), through a competitive grant process (see here).

Staff involved in this project   

Rachel Barnard qualified as a speech and language therapist from Leeds Metropolitan University in 1997. She completed a Masters in Human Communication at City University in 2005.  Rachel has worked with adults within the field of adult acquired neurology across the range of service delivery; acute, stroke unit, rehabilitation unit, community team and university clinic. Rachel developed a research interest in how team members and patients work together to create goals whilst working on the neurorehabilitation unit at the National Hospital for Neurology and Neurosurgery. A paper arising out of this research, "Strategies used in the pursuit of achievability during goal setting in rehabilitation", has been accepted for publication in Qualitative Health Research. She is currently employed as the project officer on the goal setting project working 2 days per week until March 2010.

Madeline Cruice qualified as a speech-language pathologist from the University of Queensland in 1997. She continued with further study, and worked in rehabilitation and university settings with people with acquired speech and language disorders and speech and language therapy students, before moving to London in 2002. Her doctorate explored the relationship between communication and quality of life in older people with and without aphasia. Madeline has worked as a lecturer, clinical tutor, and researcher in the Department of Language and Communication Science for nearly 7 years, and was the Programme Director for the undergraduate programme in Speech and Language Therapy for almost 4 years. She is a fulltime member of staff, and the lead for the new clinical education, innovation and enterprise project which started in January 2009. Her specific interest in goal setting is around the importance of meaningful goals and life activities arising from her quality of life research. She currently works ½ day per week on the goal setting project.

Goal setting in adult neurology: hospital, home and beyond   

Report on a study day at City University on 14th October 2009

The study day afforded us a wonderful opportunity to bring together a diverse group of clinicians and educators with a shared interest in goal setting. We were delighted with the feedback from the day, which was almost universally positive.

We started with a brief overview of the goal setting literature. Rachel Barnard presented key messages from the literature. She centred much of her talk on a paper by Levack (2006) categorising the purposes and mechanisms of goal setting, using it as a framework to pull in a wider rehabilitation literature, as well as that within speech and language therapy. Some interesting debate was raised about the conflict amongst the different purposes for goal setting. For example the conflict between supporting hope about the future with concerns about honesty or realism. She also presented literature that addressed some of the issues around the qualities of the goal itself, including debates around the SMART criteria and concepts of meaningful and person centred goals.

Madeline Cruice's talk 'clinical thinking in SLT goal setting practice' provided feedback from discussions with clinicians, educators and graduating students from the SLT Goal Setting Research Project. In answer to the question 'what constitutes good goal setting practice' there was consensus in a number of areas, including client involvement, regular review, collaborative working, and regular clear communication and documentation of goals. An area of difference between the groups was that students placed their primary emphasis on the goal itself and clinician's emphasised process. Madeline summarised that goal-setting practice is very much influenced by experience and the context in which goals are set and suggested that all parties would benefit from increased opportunities to share and learn from one another.

The next two presentations reported on research projects, one based within an inpatient rehabilitation unit and one in the community.

Rosaline Van de Weyer presented her research into involving clients in goal setting. What was particularly special about her research was that she had been able to look at the question of involvement using two very different methodologies. She presented the outcome of a quantitative study which concluded that involving patients in setting their goals did not result in the hoped for improvements in outcome on standardised measures of functional outcome. However involved patients achieved more goals than the control group and the goals were perceived as being more relevant. She also presented focus group data from both groups of patients and from clinicians. Involved patients showed increased understanding of the process and were more likely to refer to staff by name. The skills of the key worker were highlighted as a variable in the patient experience. The clinicians in her study felt that involving patients in setting their goals was best practice but reflected on the challenges associated with this.

Mark Taylor and Amy Scammell presented early findings of an exploration of the barriers experienced by health care professionals and people living with stroke when setting rehabilitation goals. Mark referred to barriers to goal setting that were intrinsic, such as language and cognition in addition to extrinsic barriers such as the environment, level of social support and access. He suggested some possible ways therapists could overcome barriers, one of the most useful tools being therapists themselves in their role as facilitators of communication. He also emphasised the importance of establishing readiness for meaningful change. There was interesting discussion regarding the potential benefits to well being of pursuing rather than necessarily achieving goals considered meaningful by the person.

Cathy Sparkes and Sam Simpson concluded the study day with an interactive presentation on person-centred goal negotiation across the client journey. They encouraged participants to look first at their personal experience of setting goals in their own lives, the language of hopes and dreams and issues of timing. This provided a foundation for considering goal negotiation for clients at different stages of readiness for change using the Prochaska and DiClemente change model, which travels through pre-contemplation, contemplation, determination, action, maintenance and relapse. They provided some practical ideas for clinicians to use, both in relation to where clients are in relation to the model and in terms of the service setting clinicians are working in. This presentation stimulated a great deal of reflection amongst participants, many of whom expressed commitment to make changes to the ways they negotiate goals with clients.

Feedback from the day indicated that participants valued the opportunity to spend a day looking at both theory and practice in goal setting. Many commented that it had been useful to consider goal setting in terms of process and that the wheel of change had been a helpful way of conceptualising and managing change. Several people called for a further event, with an emphasis on case discussion. To that end we will be inviting participants from the study day to a follow on event on Wednesday, 21st April 2010.

References

Levack, W.M.M., Dean, S.G., Siegert, R.J. & McPherson, K.M. (2006). Purposes and mechanisms of goal planning in rehabilitation: the need for a critical distinction. Disability and Rehabilitation, 28 (12), 741-749.
Prochaska, J.O. & DiClemente, C.C. (1982). Transtheoretical therapy: towards a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19 (3), 276-288.

Report on a workshop   

Goal setting workshop: deepening your practice: 21st April 2010

We were delighted and somewhat sad to close the project with this, our final event.  We entitled the day deepening your practice and the feedback we received suggests that a deeper level of thinking was certainly generated, in addition to a discernable buzz about the subject.

The first case presentation explored issues of hope and the pursuit of ambitious goals. Emma Fitzpatrick presented a young woman with a significant dysarthria who came to her with what appeared to be an unrealistic goal to talk normally.  Emma demonstrated what could be achieved by following her client's agenda and generated interesting discussion around what 'realistic' really means to the clinician, the client and the family.

Sarah Johnston gave a very honest presentation of a case that highlighted the challenges of keeping the team focussed on clients needs beyond physical recovery.  Sarah illustrated how hard it can be to keep the client and their goals at the centre of the rehabilitation process when the focus of the team is on discharge at the earliest opportunity. This was a complex, multi-facetted case that highlighted some of the implications when teams are not working cohesively. It also highlighted the importance of providing adequate training and support for the key worker role.

Lucy Rodriguez gave a poster presentation readiness for goal setting'that reflects on a man who achieved substantial change when he re-accessed inpatient rehabilitation two years after his stroke. The poster illustrates how he moved very quickly right from pre-contemplation to maintenance on the Prochaska and DiClemente model of change. Lucy suggested that the key factor in achieving change was timing, raising issues around leaving the door open for people to re-access team based intervention.

Sam Simpson and Cathy Sparkes continued on the theme of timing in their presentation client centred goal negotiation: getting the timing right. They presented a young man who was dissatisfied with the level of change he had achieved over previous episodes of intervention. They gave a powerful illustration of how identity mapping (Ylvisaker 2008) and metaphor were used to transform this mans sense of self and helped him define and achieve new goals, which resonated strongly with members of the audience.

Anna Farrell demonstrated how goals change at different stages of service provision through her case presentation goal setting across the patient journey. She highlighted the importance of good communication at points of transition. A less tangible factor impacting on goal performance in this case was the positive impact of peer relationships. This man was one of a small group of patients who regularly chatted amongst themselves about their goals, a factor which seems to have increased his engagement with the goal setting process. Videos and photos really brought this client to life.

Rachel Barnard demonstrated two of the goal setting tutorials that are being developed for City University speech and language therapist students, process and documentation, and goal setting in practice. The tutorials are expected to be complete by the middle of June. At this time two of the tutorials will be available for public viewing on the CETL in Clinical and Communication Skills website www.cetl.org.uk

Madeline Cruice led the final session of the day. Participants worked in groups to summarise their thinking, both at a clinical level and at the level of their service.  Participants took away ideas for things they wanted to do differently from each of the presentations, for example:

Participants reflected on some things that would really change their service. One key theme was the importance of flexibility, both in terms of timing of intervention and in terms of the approach taken to goal negotiation with the client. Another important theme was the need for leadership and creation of a shared MDT vision.

In summary, this was a highly stimulating day, which was made so by the excellent quality of the presentations and the willingness of participants to contribute fully to the discussions.  The workshop marked the official close of the project. However watch this space for information about publications and conference presentations arising out of the project. We will also be announcing when the tutorials are available for public viewing.