how i set goals

7/28/2019 How I set goals

1/6SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005 23

COVER STORY: HOW I...

Do you have a five year plan?

Do you have an idea of what you wish to achieve this week?

Do you have a to do list?

Will you achieve all you want to, even if all the appropriate

factors are in place and you have enough resources? Or might

tasks get left undone for no real reason that you can explain?

We all have goals in our lives, targets to be achieved, usually within a time

frame. Although we are not always successful at completing them, simply hav-

ing something to aim for seems to be important.

That is in our private lives, but what does this mean for our work with adults

with acquired communication disorders? Communicating Quality 2 (RCSLT,1996) and Clinical Guidelines by Consensus for Speech & Language Therapists

(RCSLT, 1998) both stress the importance of discussing goals - and their achieve-

ment or otherwise - with patients. Communicating Quality 2 states (p. 22) that,

throughout speech and language therapy involvement, Achievable goals will

have been identified and agreed between the speech and language therapist

and client and carer. These will include expected outcomes and time-scales.

The importance of full documentation for all appropriate professionals to

access is also highlighted. This is central to patient care and all outcomes.

However, Johnson & Faulkner stated at the 1995 RCSLT conference that Goal set-

ting is often very imprecise, partly because of our lack of confidence in making pre-

dictions This lack of confidence was evident in Portsmouth five years later, with

staff requesting training and support on goal setting. Hence we began by asking the

question:Are we setting goals with adults with acquired communication disorders?

Our department established a small descriptive case study of process with the support

of Portsmouth Institute of Medicine, Health and Social Care, Portsmouth University, tolearn what was happening locally. This involved all 21 speech and language therapists

working with adults, over a three month period, within a Primary Care Trust covering

city and rural environments, and a comprehensive range of sites and methods of ser-

vice delivery. The population covered is almost 600,000 (Census, 2001).

Questionnaire evidence (n=21) was supported by four semi-structured inter-

views. A full range of data was gathered relating to the process, factors influ-

encing goal setting and how the patient, carers and other professionals are

involved, plus examples of goals set within current cases (n=105). We used

cross case analysis to interrogate the data.

No patient information was accessed as this study did not set out to address the

appropriateness or SMARTness of the goals set. It was purely designed to look at

the process - who was involved and how. We had to get ratification from the local

Ethics and Research Committee due to new regulations regarding NHS staff and

premises. Full details of the study can be obtained from the author.The returned questionnaires gave a total of 65 goal statements, of which 16

(25 per cent) were the statement no goal set. Only one speech and language

therapist recorded setting goals always and one stated never.

The reasons given for not setting goals are in table 1.

Table 1 Reasons given for not setting goals

HOW ISET GOALSHOW WOULD YOU

GO ABOUT IT?GOAL SETTING IS MEANT TO BE INTEGRAL TO REHABILITATION BUT ITDOESNT ALWAYS HAPPEN. SARAH EASTON FINDS OUT WHAT WOULDENCOURAGE US TO DO MORE OF IT.

WHERE YOU GONNA BE IN TEN YEARS TIME

AND WILL YOU BE HAPPY WITH THE WAY YOUVE

BEEN LIVING YOUR LIFE?...

COS WHEN YOURE LOOKING BACK TO NOW ON THE

YEARS GONE BY

WILL THERE BE SOMETHING THAT YOU SAY THAT YOU SHOULDHAVE DONE RIGHT IN YOUR LIFE?

IN THE SONG TEN YEARS TIME GABRIELLE ASKS, DO YOU HAVE A

VISION? DO YOU HAVE A GOAL? OUR THREE CONTRIBUTORS REFLECT

ON THE PROCESS, ADVANTAGES AND CHALLENGES OF GOAL SETTING

WITH CLIENTS.

GOALS (1): HOW WOULD YOU GO ABOUT IT?

GOALS (2): DO YOU HAVE A MASTER PLAN?

GOALS (3): YOU WILL KNOW WHEN IT FEELS RIGHT

SARAH EASTON IS NOW TEAM LEADER FOR THE NEW COMMUNITYSTROKE REHAB TEAM AT ST MARYS HOSPITAL, MILTON ROAD,

PORTSMOUTH, PO6 3AD, TEL. 023 9228 6000 EXT 2510 OR E-MAIL

[email protected].

CAROLINE HAW, SPEECH AND LANGUAGE THERAPIST, COMMUNITY

REHABILITATION TEAM, SHEFFIELD, TEL. 0114 2716145, E-MAIL CARO-

[email protected].

SALLY BOA IS A SPEECH AND LANGUAGE THERAPIST WITH FORTH

VALLEY PRIMARY CARE OPERATING DIVISION. SHE ALSO WORKS AT THE

AAC RESEARCH UNIT IN THE PSYCHOLOGY DEPARTMENT AT THE

UNIVERSITY OF STIRLING (WWW.AACSCOTLAND.COM), E-MAIL

[email protected] OR TEL. 01786 467645.

SEE WWW.INTANDEM.CO.UK FOR DETAILS OF GOAL SETTING COURSESRUN BY CATHY SPARKES AND SAM SIMPSON.

Ten Years Time

Words & Music by Jonathan Shorten & Gabriella Bobb

Copyright Gabsongs (50%)/Universal Music Publishing Limited (50%).

Used by permission of Music Sales Limited.All Rights Reserved. International Copyright Secured.

Reason Given No. of responses

Problems writing a goal statement 5

Stage in rehabilitation 5

Find process difficult 4

Goal is implicit / carried in head 4

Impairment versus functional dilemma 3

Time consuming 2

Forget / slack practice 2

Motivation of patient 1


2/6SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 200524

We grouped factors influencing the goals set into three main themes (table 2).

Table 2 Factors influencing goals set

With all of the evidence from the questionnaires and semi-structured inter-

views, four final themes relating to goal setting with adults with acquired

communication disorders emerged:

1. The role of communication in goal setting

As speech and language therapists, we know that communication does not

just involve the adult with an acquired communication disorder. Everyone

must use consistent strategies to continue efficient and effective communica-

tion, and evidence has shown that these skills are not always consistently usedby all involved with the patient. The communication disability does affect the

goal setting process; it requires discussion, negotiation, understanding and

agreement. Even with strategies confidently in place, it takes a greater com-

mitment from everyone involved. As one member of staff commented in a

semi-structured interview, You need everyone on board to be understand-

ing.were still not that good at actually getting other people on board and

understanding what we (speech and language therapists) are trying to do.

2. The patients level of involvement in their rehabilitation

The communication disability is not the only factor to influence the patients

level of participation. The motivation to work to fulfil their goals is affected

by issues as diverse as time since onset of communication disorder, the impor-

tance of communication to the patient and their previous language use,

depression, visual problems, reduced concentration and insight, plus the level

of family and carer support.

Time since onset is also affected by current environment. Wressel et al.

(1999) wrote that people may become more passive in hospital, even if in a

rehabilitation ward. One interviewee described this in relation to a patient

who was very passive and not motivated whilst on the rehabilitation ward but

on his transfer home was far more aware of what his difficulties were and we

have actually been able to.negotiate with him

3. Dilemmas faced by speech and language therapists in the process

of goal setting

In 1984 Green wrote, Whilst communication therapy is not as amenable to

the writing of behaviourally measurable goals as the traditional didactic

approach, this need not prevent attempts being made.

Twenty years later this study has shown that some speech and language ther-

apists still find this process difficult, with a daunting range of aspects to consid-

er. We are aware of the impairment versus functional aspects, the formulation

of the goal being things to achieve rather than things to do, plus difficulties

with the measurement of communication achievement. One therapist com-

mented in a semi-structured interview, goals that are set around communica-

tion are sometimes frustratingly woolly or so specific that they loose functional

component, therefore patient and therapist question why theyve been set.

This leads to difficulties in the multi-professional forum. The most senior

therapist interviewed shared her very negative experience of writing lin-guistically based goals and then having other professionals asking her what

they meant. These impairment based goals were written without the

patients involvement. The speech and language therapist went through the

process of writing a goal, but in fact it was a list of therapy tasks. Goals need

patient involvement, with discussion, negotiation and agreement; only that

way will they be fully engaged and more likely to succeed.

Evidence emerged of variation between newly qualified and more experi-

enced therapists, the latter being much more functionally based, with more

junior members of staff focusing on impairment within the individual session.

Another aspect to take into account is the patients wishes versus the evi-

dence base. Most patients when asked say they want to speak normally. A

dilemma for the therapist is how to translate that into acceptable goals which

are measurable and achievable - and useful to all involved with the patient.

4. The type of communication disorder

We recorded the main impairment for each goal set, and differences were

identified in the interviews. Goal setting in dysphonia and dysarthria were

shown to be easier to set due to the absence of language involvement and

the acknowledgement of measurable steps, plus the fact that the patient can

be a full participant in the goal setting process.

Central to the processThe study found that we must respect the patient and their views, needs and

feelings. The type of communication impairment does affect the process, and

speech and language therapists continue to have goal setting dilemmas. In

our personal lives we dont always achieve all of our to do list; that isnt fail-

ure, so neither must it be for our patients. They are central to the process and

their drive to attempt tasks cannot be ignored especially if they dont know

what they are expected to achieve, or they just dont want to today.

Following the study, we held a full day on goal setting facilitated by CathySparkes. This involved all speech and language therapists working with adults, plus

invited guests from nursing, occupational therapy, physiotherapy and the local

Dysphasic Support. All aspects of goal setting were explored, starting with our own

personal plans and how we felt about sharing them which in fact was not that

easy. From there we moved onto the process of goal setting especially with the

added factor of communication disorder. The day ended with teams looking at

how to implement change and build our own confidence with the process.

One local issue actioned was to ensure patients are not discharged too early,

before they have moved through the various stages of rehabilitation. We

need to give them the opportunity to address their goals at various times in

various environments. We now realise that our approach to goal setting

needs to relate to where the patient is at. It may well be different in the acute

stage, with greater team than patient involvement, but it is equally important

to continue beyond therapy to Dysphasic Support. We have addressed this

recently in Portsmouth, and goal setting has become central for the adult

with an acquired communication disorder attending Dysphasic Support.

The renewed enthusiasm for goal setting that this research and the study

day provided made us realise all that is involved in good goal setting. It is not

just the writing of a statement, as it seems when making that to do list. It is

integral to good patient care and positive outcomes. It does take time and

clear communication, with the full involvement of the patient, but equally it

is core to rehabilitation. Does everyone in your team have an understanding

of what your patients are aiming to achieve, in what time scale and how best

to communicate that to all involved?

FunctionalWe must support other professionals with all aspects of communication for goal set-

ting, even if that means we do not have impairment based goals, but are support-

ing functional based goals which are not communication focused. For example, if

Factors relating to the patient No. of statements

Level of communication ability 7

Patient aims / priorities / concerns 3

Patient insight / experience 2

Patient health 1

Factors relating to family, carers, No. of statementsprofessionals

Motivation of carers / professionals 5

Level of family involvement 3

Cooperation of carers / professionals 2

Multidisciplinary team goal setting process 2

The environment 1

Factors relating to the goal setting process No. of statements

Type of disorder 4Speech and language therapists experienceor perceived ability 4

Time required 3

Impairment versus functional goals 2

To demonstrate progress or lack of it 2

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 200524

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the central goal is for a patient being to be able to access the toilet, the speech and

language therapist can play their part in supporting the patient to achieve it. Our

role would be to elicit the best way for the patient to communicate the need, and

then to ensure everyone is aware of this. This vital functional, non-impairment

based aspect of speech and language therapy must be fully recognised.

The goal setting process is also of importance in developing the skills of oth-ers, both professional and family / carers. One therapist interviewed said, I

often set goals.as a way of targeting activity for the patient but also com-

municating with the multidisciplinary team the areas of priority and potential.

Another contributor gave a brilliant example of success with a patients wife.

The goal had been fully discussed with the wife and was to use drawing in real

context when necessary. But it had not been natural for the wife, and one

wonders whether she fully understood her husbands communication prob-

lems. She told the therapist that when he had tried all day to communicate

something to her, she eventually gave him a pen and paper which led to him

drawing a bird, from which she could interpret what he was trying to say.

We must also have confidence in our skills and equally must review and

reflect on the process so that our skills develop further. In researching this

topic I found relatively little, especially in speech and language therapy, to

demonstrate what most professionals were doing. Here in Portsmouth we

have set up a small group to provide support and advice, and devised new

documentation for us all to use. A member of the team has reviewed the

multi-professional documentation used for goal setting on a stroke rehabili-

tation ward, which has resulted in an increase in the communication skills

used on the ward by all professionals and carers. This supports the important

fundamental that goal setting is central to all rehabilitation.

All of this has begun to increase our confidence in this important aspect of the

rehabilitation of acquired communication disorders. When did your team last

review this core aspect of rehabilitation? Should it go on your to do list?

AcknowledgementsWith many thanks to Cathy Sparks for her interesting and informative day

plus advice, and to everyone in Portsmouth who has supported this study.

Sarah Easton is a specialist speech and language therapist with Portsmouth

City Teaching PCT.

ReferencesGreen, G. (1984) Communication in aphasia therapy: some of the procedures and issues

involved. British Journal of Disorders of Communication, 19, pp. 35-46.

Office of National Statistics (2001) Census. Available at www.statistics.gov.uk

(Accessed: 5 July 2005).

Royal College of Speech and Language Therapists (1996) Communicating Quality 2:

Professional standards for speech and language therapists. London: RCSLT.

Royal College of Speech and Language Therapists (1998) Clinical Guidelines byConsensus for Speech and Language Therapists. London: RCSLT.

Wressel, E., Oberg, B. & Henriksson, C. (1999) The rehabilitation process for the

geriatric stroke patient an exploratory study of goal setting and interventions,

Disability and Rehabilitation, 21(2), pp. 80-87.

Our interdisciplinary Community Rehabilitation Team has a

remit to facilitate early hospital discharge for patients fol-

lowing stroke. There is considerable energy for new ideas

and ways of working, providing a very stimulating working

environment. A physiotherapy colleague and I decided to

produce a patient information leaflet, as all team members

felt it would be useful. My particular interest was in something suitable for

clients with aphasia in the acute stage after a stroke.

At the same time, we were keen to take the opportunity to get away from the

notion that, as the health professionals, we would know best. Patients them-

selves usually know best, since they hold explicit or implicit hopes for their recov-

ery (Clark & Smith, 1998; Wade, 1998). Fostering self-determination in clients can

have very positive outcomes, but requires a shift in the balance of power, and

finding a way to enable clients to express their hopes (Worrall, 2000).

We started to think about the importance of negotiating goals with clients

(and carers), both as something to work towards, and as a way of staging

their - sometimes unrealistic - long-term goals into more tangible short-term

therapy goals. This standard approach would be completely different from

our established goal setting process, which had been entirely controlled by

therapists, away from patients in our weekly review meeting.

There is considerable support in the literature for providing clients and car-

ers with both the information they need (see for example Hangar & Mulley,

1993) and the means to express their goals (see for example Baker et al., 2001).

For our rehabilitation team, with its clear-cut resources and interdisciplinary

style, it was practical to combine these two needs into a client-held booklet.

The development of the booklet was a lengthy process during which much

discussion and many drafts were aired. We depended on dedicated and

expert help from secretarial staff.

Ideas for content were derived from a variety of sources including the pub-

lished literature (particularly Stroke Association), colleagues and clients and

carers. We agreed it was important to

1.Bring information together in one A4 format2.Make it of immediate use and not easy to misplace

3.Have a reasonably large text size

4.Have parts that could be customised (such as goal setting and space for

extra information sheets).

The booklet was developed with clients who had had a stroke in mind. It

incorporates picture material (photographs, pictures to illustrate the text and

pictures drawn especially to illustrate goal setting) which - although designed

to ensure access to clients with aphasia and to provide them with a communi-

cation tool - would have appeal to all clients. The written text is simple in style

and presented in both paragraph and bullet point form. Colour-coded pages

make navigation as easy as possible and may provide extra visual appeal.

Having trialled the booklet informally, we had a grand launch in July 2001

with follow-up training sessions to reach all 40 team members. We wanted to

ensure that everyone - core staff, administration and clerical, stroke liaison

nurses, home care staff understood the importance of the booklet and

shared sufficient information to use it. They also needed the opportunity to

raise questions, and this process continues via staff meetings.

I ran a pilot study to find out if and how the booklet was being used, par-

ticularly in relation to goal setting, and to explore what clients thought of it.

Ten clients took part. I used purposive sampling to try to capture the range of

clients seen by the team in terms of age, sex, disability and geographical area.

A week after discharge from the community rehabilitation team, I contact-

ed potential interviewees by telephone. All agreed to a visit at home to dis-

cuss the booklet, and I arranged this for a short time after the phone call.

Three clients had acquired language disorders, two had acquired speech dis-

orders and two had memory impairment. All ten were back living in their own

homes, one of them living alone, and all had been treated by other team

members for mobility / activities of daily living issues.

I conducted interviews according to a format developed to capture the range of

THE DEVELOPMENT OF A COMMUNITY REHABILITATION TEAMINFORMATION BOOKLET PROVIDED CAROLINE HAW WITH A PERFECTOPPORTUNITY TO FACILITATE AND STANDARDISE GOAL SETTINGWITH CLIENTS.

DO YOU HAVE AMASTER PLAN?


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All except one indicated an understanding of these concepts which is broadly

consistent with a rehabilitation therapists approach. Some participants added

their own perceptions, such as short-term goals being priorities and the

more simple things. Some comments demonstrated that a patients under-

standing of how long recovery may take changes over time, that this under-

standing only comes with experience and that individuals may need differing

amounts of time or therapy to achieve similar levels of recovery.

Theme 4: Involvement of clients in goal setting

Seven clients had goals written in their booklets. Of the other three, one had

goals from a hospital rehabilitation file, one had completed a list of problems

but did not feel ready to set goals and one with only physical impairment was

clear that my goal is to get back to normality.Participants were asked to reflect upon their own experience; to consider whether

they / the team had set the right goals, whether they had worked towards these

specified goals and whether they had achieved their target goals. Seven stated that

they had set the right goals, worked on the goals set and achieved all or some of

the goals set. Although they had no alternative experience for comparison, partici-

pants were asked what they thought of being involved in setting goals.

An important basic theme was setting your own goals (8 out of 10 would do

this, one wanted to set goals with a therapist, another wanted a therapist to

tell her what to do) and measuring progress against your own standards. Goal

setting was experienced as a positive approach.

Theme 5: Clients perceptions of outcome

Participants were asked to comment on whether the booklet helped rehabilita-

tion, made no difference, or got in the way of it. Nine out of 10 said the informa-

tion had helped rehabilitation, one that it made no difference. Eight out of 10 said

the goal setting had helped rehabilitation. One, a client with memory problems

and concomitant distress, felt it might do in time. Another said it had got in the

way of rehabilitation. It might be significant that, in addition to a chronic health

problems, a degree of cognitive impairment and severe communication disability,

both she and her husband presented with a pessimistic view of rehabilitation.

Theme 6: Variation in the process

With therapists and clients bringing individual styles to the process and the cus-

tomisable design of the booklet, we expected a degree of variation in how the

booklet was used. However, we werent prepared for variation in its presentation

(for example, photos not provided, working pages and plastic wallet rarely used).

Exploration of the process of goal setting showed great variation: four clients

had completed a problem list to inform goal setting goals were written down

by either clients or therapists; one had used the picture page to inform goals,

which she and the therapist had written together; one had used an extra reha-

bilitation file in which he had been involved with goal setting in hospital; one

could not remember the process; one said she did not use the goal setting part

of the booklet [but that she had worked with the team on goals]; one wrote

a problem list with the therapist but did not set goals; one commented I was

doing it off my own bat and did not have any written goals.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 200526

questions posed by the study objectives. I piloted a draft structured interview sched-

ule on two clients. The style of questioning was designed to make it accessible to all

clients, including those with speech and language disabilities. The interview used

open questions, 05 rating scales, multiple-choice questions and closed (yes / no)

questions. I used clinical skill to gain as much participation as possible, for example

where appropriate the use of single written words. All interviews were within a sixweek period to control for potential variables external to the individual clients.

I examined the data for six themes:

Theme 1: Accessibility

a) Clients opinions included

b) A 05 rating scale gauged the usefulness of each section of the booklet

and a formula was used to assign a score (Useful = 4-5, Dont know = 3, Not

useful = 1-2, Not applicable = 0).

The sections for team description and goal setting scored highest. In

some cases, sections of the booklet had not been used.

Theme 2: Clients awareness of the purpose of the booklet

For all except one, the booklet was seen as closely related to the rehabilita-

tion process. Two comments underlined the booklets role in motivating

clients.

Theme 3: Understanding the rehabilitation process

This refers to the rehabilitation process from the therapists viewpoint. Clients

sometimes hope to achieve too much too soon or do not have an under-

standing of the small steps needed to achieve larger scale goals. Participants

were asked to say what they understood by the terms long and short-term

goals. This was not easy for the communication-impaired participants to

respond to.

Pictures:Theyre self-explanatory - you can understand them.

Font size:Yes its good as well because I have a bit of trouble with my eyes.

Differrent coloured pages:It didnt really make any difference.

Yes thats handy as well, you can pick out different things you want to

learn about.

General layout:Alright because its not official looking so its easy to read - I found thoseleaflets (Stroke Association) more scary.

I think its important because they know how they feel you cant

fully realise what its like to have a stroke.

I would do it together.

Its a good. [thumbs up]

From my point of view I think its encouraging if you set your own

goals and you achieve them it encourages you to carry on.

Obviously in the long-term you have to be able to be capable soyou have to recover more to achieve them. [Short-term] should bethe more simple things in life equally as important if not more eg.washing yourself.

[long-term] Means future, [short-term] means tomorrow.

[long-term] Going on how long its taking me no good thinkingyou can do everything in a couple of months is it so most thingswill be long-term youd like em to be short-term.

I cant get going with that, I cant think about it.

Remember I wasnt in a mental condition to accept it, but patientswho were were in a position to garnish something from it.

Its to write down your progress and also to inform you on strokesand how to go about it.

Its to help you to get your use back, to do different things. I think itencourages you to get on with it. Im doing my exercises every day.

Goal.

Usefulness

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As a speech and language therapist within a multidisciplinary

community rehabilitation team, I have grappled for many

years with the theoretical and practical aspects of negotiating

realistic, meaningful rehabilitation goals with clients. My

interest in goal planning stems from clinical work as well as a

research project I undertook in 2003. This examined whetheror not the low tech Talking Mats framework (Murphy, 1998)

could be used to help people identify rehabilitation goals. A recent study day

gave me a further opportunity to consider goal setting frameworks (Sparkes &

Simpson, 2005) and to answer some of the questions raised by my pilot study.

Goal planning is an essential component of rehabilitation services. According to

Schut & Stam (1994, p. 223), Goal setting is a prerequisite for interdisciplinary team-

work. They state (p. 224) that goals must:

1. Be relevant and motivating

2. Express what you want to accomplish

3. Be positively defined

4. Be put in behavioural terms

5. Be explicit and commonly understandable

6. Be attainable and enabling well-balanced planning

7. Enable measurement.

Schut & Stam (1994, p. 224) also stress the importance of involving the person in the

goal setting process:

Something relevant for the therapist may be regarded as completely irrelevant

by the patient and / or the other way round. If the patient does not regard a goal

as relevant, the team runs the risk that its efforts are in vain; the patient is not

motivated to work at an irrelevant goal.

The Brain Injury Resource Center (1998) states that The ability to set goals is essential to

effective problem solving: and by default, is essential to self management, and self

determination. Given that goal planning is essential to planning effective rehabilitation,

it is important that all users of a service should be allowed to participate as fully as pos-

sible in the process. It can be difficult for people with communication and / or cognitive

impairments to do this and often rehabilitation teams rely on their own ingenuity and

persistence in order to obtain the views of this group (Wade, 1999, p. 21).

My pilot study (Boa & McFadyen, 2003) focused on helping people to consider things

that they wanted to change. The aim was to see if the use of Talking Mats could

help people become more involved in the process of goal planning and help them

understand what we mean by goals.

The Activities and Participation component of the International Classification of

Functioning, Disability and Health framework (WHO, 2001) provides us with a com-

prehensive list of domains which relate to life areas. I used these as a guide for the

Talking Mats symbols, and the participants built up a personal picture of specific

problems or issues. Initially participants were asked to consider broad topic areas.

They then selected topics that they wanted to explore in greater detail. For example,

this mat shows that the participants main areas of concern in terms of broad topics

were mobility, self-care, leisure, health and using transport:

Using self care as the sub-topic resulted in this mat:

This showed that the participant was concerned with many aspects of self care. Using

the mats helped her to think about her many difficulties one at a time. Discussing

issues in this way enabled her to think about realistic goals, and also to consider pos-

itive aspects of some of the issues.

Talking Mats does not provide a written goal plan as such. Rather, it helps

people identify problems or issues. Further refinement and negotiation

needs to take place if we are to translate these into goals. It does however

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005 27

COVER STORY: HOW I

SALLY BOA ALREADY HAD THE MOTIVATION AND A VARIETY OF TOOLS BUT LEARNING ABOUT A STRUCTURED NEGOTIATION FRAMEWORKHELPED CEMENT HER GOAL SETTING SKILLS.

YOU WILL KNOW WHENIT FEELS RIGHT

Further themes emerged that are beyond the scope of this pilot:

1. The timing of the booklet, of information-provision and goal setting

2. The context of goal setting: how does the use of the booklet link with

therapists weekly goal setting meetings?

3. The responses to the interviews - due to the nature of their expressive and

receptive language difficulties, the aphasic clients were not able to participateas fully as the non-aphasic clients. A future study could focus on a) a

greater number of aphasic clients b) the use of extra picture resources to

supplement the booklet and c) a more modified, aphasia-focused interview.

4. Responses of the clients with cognitive / memory difficulties.

The complexities of the therapeutic relationship are multiplied many times in an

interdisciplinary community context. With our team intervention limited to 12 inten-

sive weeks, a booklet such as Whats Your Goal?may be a useful tool for facilitating

a quick engagement with the team at a very important time. It may also be a prac-

tically useful way of understanding the service provided, allowing clients, carers and

therapists a means of talking about the rehabilitation process as a shared event.

Caroline Haw is a speech and language therapist with the Community

Rehabilitation Team, Sheffield South West Primary Care Trust.

AcknowledgementsMy sincere thanks to colleagues in the Community Rehabilitation Team,

Sheffield, my managers and administrative staff, research lead Mark Parkerand physiotherapist Morag Hutchinson.

ReferencesBaker, S.M., Marshak, H.H., Rice, G.T. & Zimmerman, G.J. (2001) Patient participation in physi-

cal therapy goal-setting, Physical Therapy, May 81(5), pp. 1118-26.

Clark, M.S. & Smith, D.S. (1998) The effects of depression and abnormal illness behaviour on

outcome following rehabilitation from stroke, Clinical Rehabilitation, 12, pp. 73-80.

Hangar, H.C. & Mulley, G.P. (1993) Questions People Ask About Stroke, Stroke 24, pp. 536-8.

Wade, D.T. (1998) Rehabilitation is always given a low priority, Clinical Rehabilitation, 12, pp. 1-2.

Worrall, L.E. (2000) The influence of professional values on the functional communication

approach in aphasia, in Worrall, L.E. & Frattali, C.M. (ed.) Neurogenic Communication Disorders :

A Functional Approach. New York: Thieme Medical Publishers.


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COVER STORY: HOW I

allow us to have a visual record (captured with a digital camera) so that

changes in peoples priorities can be monitored.

The project demonstrated that Talking Mats is a useful tool that can be used to

help people to engage in the goal planning process, but it also left me with a num-

ber of questions. A recent study day Goal Negotiation: a shared journey gave me

an opportunity to find some answers.

Presenters Cathy Sparkes and Sam Simpson are speech and language thera-

pists who have worked for many years within multidisciplinary teams and

now share their expertise through a joint venture, www.intandem.co.uk.

They described their goal negotiation framework through a combination offormal presentation, practical exercises and discussion which balanced theory

and practice. Their broad framework enables us to:

* explore issues with our clients;

* seek clients opinions right from the beginning; and

* offer choices which are relevant and motivating.

Goal planning is complex and requires a great deal of skill and flexibility. The key

message from Cathy and Sam was that goal planning is aprocess rather than an end

in itself. This can often be overlooked by professionals in busy rehabilitation teams

where the emphasis may be on producing written goal plans within certain time

scales. By focusing on the outcome - rather than theprocess - we are doing the peo-

ple we work with a disservice, and perhaps are not really listening to them. The goal

negotiation framework takes us logically through a progression which ensures we

dont miss out these important steps, and ultimately results in relevant, motivating

and realistic goals which have been negotiated with each individual. Each stage

needs to be respected so that the individual can have the time and opportunity to

explore their rehabilitation goals and their hopes and aspirations fully.

Talking Mats is one example of a tool that fits into the Sparkes & Simpson goal

negotiation framework. The study day helped answer questions raised by my pilot

study (Boa & McFadyen, 2003):

1. What other methods can we use to help people gain an understanding of

rehabilitation goals?

By using visual methods creatively to represent what we mean, we can find

out what clients see as a goal. Taking time at this stage means we can real-

ly listen to what people are saying from the beginning. A main focus of the

study day was helping us as clinicians think more creatively about how we

present the concept of goals to people. We reflected on what the word

goal meant to each of us, and spent time thinking how we might represent

this visually. The significant amount of time spent on this made me question

whether we spend enough time explaining the concept of goals to the peo-ple we are trying to help. This important first step in the goal negotiation

journey needs to be continued through the use of symbols, drawings, options

and choices as problems are identified and negotiated into goals.

2. At what stage should we be setting goals with people and how long

does this process take?

Goal negotiation is a continuous process and should not be rushed. One of the first

stages is to identify the clients own strengths, problems, aspirations and life goals,

then to work out what they might be able to change in the context within which

you are both working. Tools such as Talking Mats can be used alongside other

methods such as drawing and appropriate analogies for individual clients (for exam-

ple, going on a journey or thinking of different steps on a ladder).

3. How can we bridge the gap between helping people to identify issues or

things that are difficult, and translating these into goals?

It can be relatively easy for people to identify problems, but the difficult task

is often translating these into goals which are realistic, meaningful and can be

measured. Relating problems to real life contexts - and helping clients to see

what they want to change and what they are happy to settle for - can help

them to prioritise and sort out the precise areas they want to work on. This

gives both client and therapist a clear path and direction.

4. How can we help clients to understand and relate to the actual written

document (the goal plan)?With goal planning providing direction for therapy, it is essential that our clients can

relate to and understand the written document, so that it can be referred to and

changed during the therapy process. Engaging people in the process of setting goals

from the very beginning exploring the meaning of goal, thinking about long-

term and short-term goals, considering the steps needed to get there - will ensure

that the written document will be relevant.

Tools such as lifestyle grids (Jeffers, 1987), Mind Maps and Talking Mats can help us pro-

duce visual materials which are meaningful and have been constructed jointly with our

clients. This results in a sense of common understanding, ownership and empowerment.

Goal planning is a process that takes time, effort and skill. The goal planning frame-

work (Sparkes & Simpson, 2005) provides us with a structure to ensure that the mul-

tidisciplinary team is involving people in a way that they can understand, right from

the beginning of rehabilitation. Using the framework helps us to consider individu-

als and the situations and environments they are in, helps them to identify strengths,

problems, aspirations and priorities and ultimately allows goals to be negotiated.

Within this framework, a number of tools can be used, as well as our skills of nego-

tiation. These tools, along with structures such as the International Classification of

Functioning domains (WHO, 2001), ensure we no longer need to rely on our inge-

nuity and persistence (Wade, 1999), but that we can draw from a variety of

resources. By doing this we can embark on the journey of negotiating goals with our

clients, starting from a point of shared understanding and partnership.

Sally Boa is a speech and language therapist in Forth Valley and at the AAC Research

Unit, University of Stirling.

ReferencesBoa, S. & McFadyen, L. (2003) Goal Setting for People with Communication Difficulites, CommunicationMatters 17(3), pp. 31-33.Brain Injury Resource Center (1998) Goal setting. Available at: http://www.headinjury.com/goalset.htm(Accessed: 3 July 2005).

Jeffers, S. (1987) Feel the fear and do it anyway. London: Arrow Books.Murphy, J. (1998) Talking Mats: Speech and language research in practice, Speech & Language Therapyin Practice. Autumn, pp. 11-14.Schut, H.A. & Stam, H. J. (1994) Goals in rehabilitation teamwork, Disability and Rehabilitation 16(4),pp. 223-226.Sparkes, C. & Simpson, S. (2005) Goal negotiation: a shared journey: Adult Acquired Disorders (Scotland)Special Interest Group study day. Perth 10 February.Wade DT. (1999) Goal Planning in Stroke Rehabilitation: How?, Topics in Stroke Rehabiltation 6(2),pp.160-36.World Health Organisation (2001) ICF: International Classification of Functioning, Disability and Health.Geneva: WHO. Available at: www.who.int/entity/classifications/icf/en/ (Accessed: 19 July 2005).

Resources* Mind Maps - see www.mind-map.com* Talking Mats, see www.talkingmats.com

HPC websiteThe Health Professions Council has overhauled its website to make it easier

for professionals and members of the public to use.

www.hpc-uk.org

Vocabulary softwareLDA Language Cards Interactive is a series of basic language skills CD-ROMS

for PC and Mac. It includes three programs - Nouns, Verbs, Prepositions &

Adjectives - to help pupils build and consolidate a strong vocabulary. Speech

or text can be switched off and there are four levels of difficulty.

www.sherston.com

Learn from the expertsA series of pamphlets written by and for young people with an acquired

brain injury - Learning from the experts - is downloadable free at

www.cbituk.org.

Photodynamic TherapyA new charity aims to raise awareness of and funds for research into

Photodynamic Therapy for cancer. Pre-cancer and early cancer of the mouth

are among the conditions thought to be most suitable for this type of

treatment.

www.killingcancer.co.uk

resources

how i set goals

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