Patient Education and Counseling 85 (2011) 206–213

Health Care

Navigating patient-centered goal setting in inpatient stroke rehabilitation: Howclinicians control the process to meet perceived professional responsibilities

William M.M. Levack a,*, Sarah Gerard Dean b, Richard John Siegert c, Kath Margaret McPherson d

a Rehabilitation Teaching and Research Unit, Wellington School of Medicine and Health Science, University of Otago, Wellington, New Zealandb Peninsula College of Medicine and Dentistry, University of Exeter, UKc King’s College London, Palliative Care, Policy and Rehabilitation, UKd Person Centred Research Centre, Division of Rehabilitation and Occupation Studies, AUT University, Auckland, New Zealand

A R T I C L E I N F O

Article history:

Received 29 July 2010

Received in revised form 6 January 2011

Accepted 8 January 2011

Keywords:

Goal setting

Patient-centered practice

Stroke rehabilitation

Interdisciplinary teamwork

Qualitative research

A B S T R A C T

Objective: Patient-centered goal setting, while central to contemporary rehabilitation, has been

associated with growing uncertainty regarding its application in clinical practice. We aimed to

examine the application of goal setting in inpatient stroke rehabilitation.

Methods: Data collected from 44 participants (nine patients, seven family members, 28 health

professionals), using multiple data sources (interviews, recorded clinical sessions, team meetings,

participant-observation, and clinical documentation), were analyzed using constant comparative

methods.

Results: Certain goals (characterized by short timeframes, conservative estimation of outcomes, and

physical function) were privileged over others. Involvement of patients and family in goal setting

resulted in interactional dilemmas when their objectives, skills and perceived capacity did not align with

privileged goals. When alignment did occur, greater patient involvement still did not appear to influence

clinical reasoning.

Conclusion: This study raises questions about how ‘patient-centered’ current goal setting practices are

and whether a ‘patient-centered’ approach is even possible in inpatient stroke rehabilitation when

considering predominant funding and health system models.

Practice implications: For ‘patient-centered’ goal setting to be more than rhetorical, clinicians need to

examine the values they attribute to certain types of goals, the influence of organizational drivers on goal

selection, and how goals are actually used to influence clinical practice.

� 2011 Elsevier Ireland Ltd. All rights reserved.

Contents lists available at ScienceDirect

Patient Education and Counseling

jo ur n al h o mep ag e: w ww .e lsev ier . co m / loc ate /p ated u co u

1. Introduction

Goal setting and patient-centered practice are concepts thathave increasingly dominated discourse on rehabilitation over thepast few decades. These concepts have been described as essentialfeatures of any successful rehabilitation program [1,2] and areintimately related, with patient involvement in goal settingpresented as one way (if not the primary way) of enhancingpatient-centeredness in rehabilitation contexts [3,4].

However, goal setting, while promoted by some as a relativelysimple, straightforward way to structure interactions with patients[5], appears to serve a range of different, sometimes conflicting,functions within rehabilitation [6,7]. Terms related to goal settingin rehabilitation have been used to refer to multiple different

* Corresponding author at: Rehabilitation Teaching and Research Unit, University

of Otago (Wellington), PO Box 7343, Wellington South, New Zealand.

Tel.: +64 4 385 5591x6279; fax: +64 4 389 5427.

E-mail address: william.levack@otago.ac.nz (William M.M. Levack).

0738-3991/$ – see front matter � 2011 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.pec.2011.01.011

concepts (e.g. the hopes, ambitions, or expectations of patients,family members, clinicians or health funders in the short, mediumor long term) with no consensus yet existing around key goalsetting terminology [6–8]. Theories regarding the effects of goalsetting have been imported from psychology with little empiricaltesting in rehabilitation environments [8,9]. Indeed, a recentsystematic review concluded that the evidence regarding anygeneralisable effect of goal setting on patient outcomes followingrehabilitation was inconsistent at best and greatly limited by thequality of studies published to date [10].

Likewise, while the concept of ‘patient-centeredness’ appearscommonsense, it has defied easy description. Conceptual analyseshave demonstrated this concept is multi-factorial and difficult toevaluate [11,12]. In general however, patient-centerednessappears to include notions of a biopsychosocial perspective onhealth, empowerment of patients to participate in clinicaldecision-making, consideration of patients within their lifecontext, and respecting the patient as a person [11,12]. Further-more, as for goal setting, evidence regarding the effectiveness ofpatient-centered strategies to change health outcomes (beyond

W.M.M. Levack et al. / Patient Education and Counseling 85 (2011) 206–213 207

secondary outcomes such as improving patient satisfaction) hasappeared inconsistent or difficult to interpret [13,14].

While there have been a number of previous qualitativeinvestigations into clinician and consumer perspectives on goalsetting in rehabilitation, these have largely been based on datacollected via focus groups or semi-structured interviews [3,7,15–22]. Thus these studies have represented perceptions of practicerather than observed practice. Only two qualitative studies to ourknowledge have included analysis of observational data of goalsetting as it occurs in clinical environments, both involving singleepisodes of clinical interactions [23,24]. The objective of this studywas to investigate, by observation and interview, the application ofgoal setting during a series of cases of inpatient stroke rehabilitation.

2. Method

2.1. Research design

This study employed constructivist grounded theory [25] toinvestigate the application of goal setting in inpatient rehabilita-tion for people with stroke. Data collection centered on goal settingas it was applied to a selection of clinical cases: each ‘case’ being anepisode of inpatient rehabilitation for an individual patientadmitted to hospital with a primary diagnosis of stroke. A RegionalEthics Committee gave approval for this study to be conducted.

2.2. Participant selection and recruitment

Participants were recruited from two inpatient rehabilitationunits in two separate public hospitals and were eligible forinclusion if they had been admitted to hospital for issues primarilyrelated to acute stroke. Purposeful sampling was used to selectparticipants to ensure the study group included men and women,people of different ages, different ethnicities, and differentseverities of stroke [25]. Theoretical sampling was used forselection of the last few cases to recruit participants with whomwe could specifically explore the relationships among the coreconcepts emerging from the data [25]. Family members andclinicians were eligible to participate if they were involved inclinical discussions regarding the participating patients. Allparticipants provided written informed consent. Any patientsassessed as unable to provide informed consent had writtenconsent provided on their behalf by a next-of-kin.

2.3. Data collection

Data were collected by the field researcher (WL) over twoseparate four month periods during 2007, and from multiplesources: interviews with patients, family members and clinicians;open-recording of clinical assessments, therapy sessions, andinterdisciplinary team (IDT) meetings; participant-observation;and from clinical documentation. Participant-observation involvedspending extended periods of time (at least 4 h for every hour ofaudio-recorded data) on the wards talking to patients and theirfamilies, attending ward meetings, and observing assessments,therapy sessions and other clinical activities. Audio-recorded data(28 h in total) included the recording of both interviews andclinical events, and were used to complement participant-observation rather than to supersede it. Information gained fromparticipant-observation assisted with the identification of clinicalsession in which goal setting was most likely to be discussed withpatients or by team members. Purposeful sampling and (later)theoretical sampling [25] were also used to decide which sourcesof data to audio-record and when. For example, we pursuedopportunities for interviews with specific clinicians or familymembers when it became apparent they were increasingly

involved in the planning of rehabilitation for a particular case.Thus, while sampling of data was informed by the concepts,themes and ideas emerging from the study, it was also based onobservation of each case as it unfolded.

All interviews followed a semi-structured, open-ended format,and were transcribed verbatim. An iterative approach was taken tothe selection of interview topics, with analysis of initial datainfluencing the choice of questions in subsequent interviews. Eachinterview was accompanied by periods of observation on the wardand informal discussion with patients, family members or cliniciansabout the case. Interviews included questions related to theparticipants’ perspectives on how goal setting had occurred forindividual patients, what had been learnt, how this information wasused, and the nature of future objectives. Patients or (if they wereunable to communicate) their family members participated in 1–2recorded interviews during the course of their inpatient stay and onemore in the community three months after discharge from hospital.

2.4. Data analysis

Data collection and data analysis occurred concurrently. Textfrom field notes, interview transcripts, recorded meetings andclinical sessions, and documentation from patient files were alltreated equally as study data and analyzed in a similar way. Codingand categorization of data followed the constant comparisonmethod of grounded theory [25]. Data were read and coded (byWL), with subsequent re-reading and coding incorporatingfindings from new interview and observational data as it wasgathered. Initial coding was undertaken on a line-by-line basis. Therelationships between and within concepts emerging from thiscoding were explored with increasingly higher levels of concep-tualization and supplemented by the use of memo-writing anddiagramming. Data collection occurred until data saturation wasreached; that is, until we believed that the collection of new datawould not significantly alter the construction of the theory thatemerged from this study [26].

Several strategies were employed to ensure the credibility andtrustworthiness of the emerging theory. The field researcher (WL)debriefed regularly with the other three authors after sets ofinterviews or periods of data collection. This debriefing ensuredchoices regarding theoretical sampling were justifiable, that theprocess of data collection and analysis was auditable, and thatdecisions regarding when to stop collecting data for any oneparticular case could be defended. Negative case analysis was usedto challenge and enrich the themes and concepts which arose fromthe data, further adding to the credibility and trustworthiness ofthe emerging theory [26]. In addition, one other researcher (SD)independently coded 15% (just over 4 h) of the audio-recorded dataand associated field notes. The purpose of this peer-coding of datawas to enhance the breadth of interpretation and to ensure that thethemes highlighted in the analysis did in fact arise out of the data,instead of being imposed on it, as is consistent with constructivistgrounded theory [25]. Extracts from data are presented (withpseudonyms) to support the findings below.

3. Results

3.1. Participants characteristics

Forty-four people participated in the study including ninepatients, seven family members (two spouses and five adultoffspring), and 28 health professionals. The participating cliniciansincluded six physicians, 11 registered nurses, four physiotherapists(PT), three occupational therapists (OT), two social workers, onespeech language therapist, and one cultural advisor. See Table 1 forcharacteristics of the participating patients.

Table 1Characteristics of participating patients and overview of audio-recorded data collected.

Sex Age Ethnicity Pre-stroke marital, liv-

ing, and work status

LOSa (days) Insult Presentation on admission Discharge

destination

Audio-recorded Data

P1 M 86 NZ Asian Living with wife, part-

time voluntary work

75 (54) Bilateral

CVA

Able to walk with frame plus assistance of two,

needing maximal assistance with all activities of

daily living, moderate cognitive impairments,

slurred speech, very fatigued

Hospital-level

care rest home

Observational data (1 h total): 1st goal setting

meeting with P1, 1st physiotherapy (PT) session,

1st occupational therapy (OT) session, 7� IDT

meetings

Interview data (2 h total): 3� interviews with P1

and spouse, 2� PT interviews, 1� OT interview,

1� physician interview, 1� social work (SW)

interview

P2 F 90 NZ European Divorced, living alone,

retired

26 (20) Right CVA Walking with supervision (balance impaired), no

cognitive impairment, slurred speech

Own home Interview data (1 h total): 2� interviews with P2,

1� interview with PT, 1� interview with OT, 1�interview with nurse, 1� interview with SW

P3 M 67 NZ European Married, living in own

home, working part-

time

18 (14) Left CVA Walking with supervision (balance impaired),

weakness and loss of dexterity in right arm/hand,

mild dysphasia

Own home,

return to work

Observational data (1 h total): 1st PT session, 1st

OT session, 1st physician session, 1� IDT meeting

Interview data (1 h total): 3� interviews with P3,

1� interview with PT, 1� interview with nurse

P4 F 68 Pacific Islander Widowed, living with

daughter, not working

73 (69) Right CVA Unable to sit unsupported, needing maximal

assistance with all activities of daily living,

moderate cognitive impairments, limited English

Daughter’s

home

Observational data (1 h total): 1st PT session, 1�family meeting with IDT, 7x IDT meetings

Interview data (3 h total): 2� interview with

daughter, 2� PT interviews, 1� OT interview, 2�nurse interview, 1� cultural advisor interview

P5 F 72 NZ European Widowed, living in

own home

19 (13) Cerebellar

infarct

Walking with frame plus assistance of one, no

cognitive or communicative impairments

Own home Observational data ( h total): 1st PT session, 1st OT

session, 1� IDT meeting

Interview data (1 h total): 2� interviews with P5,

1� nurse interview

P6 M 82 NZ European Married, living in own

home, retired

52 (40) Cerebellar

infarct

Unable to walk but standing and transferring from

bed to chair with assistance of one, mild cognitive

impairment, very fatigued

Own home Observational data (1 h total): 1st goal setting

meeting with P6, 1st PT session, 1st OT session, 2�IDT meetings

Interview data (1 h total): 2� interviews with P6

(1 with spouse present), 1� interview with OT

P7 F 78 NZ European Widowed, living in

own home, working

part-time

44 (34) Right CVA Unable to sit unsupported, needing maximal

assistance with all activities of daily living, no

cognitive or communicative impairment

Hospital-level

care rest home

Observational data (3 h total): 1st goal setting

meeting with P7, 4� PT sessions, 1st OT session,

4� IDT meetings

Interview data (1 h total): 3� interviews with P7,

1� PT interview, 1� physician interview

P8 M 57 NZ European Married, living in own

home, working full

time

18 (10) Cerebellar

bleed

Walking with supervision (balance impaired), no

cognitive or communicative impairment

Own home,

return to work

Observational data ( h total): 1� IDT meeting

Interview data (1 h total): 2� patient interviews

P9 F 92 NZ European Widowed, living in

own home with son,

retired

90 (78) Left CVA Independently mobile, severe expressive and

receptive dysphasia, unable to participate in

cognitive assessment

Hospital-level

care rest home

Observational data ( h total): 1� SLT meeting, 3�MDT meetings

Interview data (1 h total): 1� interview with son,

1� interview with keyworker, 2� interview with

speech language therapist

a LOS = length of stay in hospital, with LOS in the rehabilitation ward in parentheses.

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3.2. Goal setting characteristics

Both rehabilitation units used a documented IDT plan for eachpatient on which goals were written. Both had establishedprotocols for gathering information about the views held bypatients and family regarding their aims for rehabilitation (knownas ‘patient and family goals’). Both units nominated staff membersto collect this information using a structured questionnaire, beforetransferring any elicited goals to the patient’s IDT plan.

In addition to patient and family goals, both units alsodocumented shared team goals on the IDT plan (hereafter referredto as ‘IDT goals’), which were ostensibly derived from the patientand family goals. In total, 45 IDT goals were documented for thenine patients involved in this study, ranging from one to 14 goalsper individual case.

Table 2Traits of privileged goals.

Trait of privileged goals

1. Orientation towards physical functioning

2. Short timeframes for goal achievement

3. Conservative estimations of progress

3.3. Overview of key findings

From the data gathered, we constructed a substantive theorywhich linked two key themes related to the application of goalsetting in inpatient rehabilitation for people with stroke. Thefirst of these themes was the privileging (prioritization andpromotion) of certain goals within the system of inpatientrehabilitation. The second theme, entitled ‘the borderlands ofpatient-centered goal setting’, related to the unknown andunpredictable nature of conversations with patients and familieswhen attempts were made by clinicians to engage with themover goal setting.

The substantive theory constructed from this study describedthe consequences arising from attempting to navigate throughpatient-centered goal setting in an environment where certain

Examples

Researcher: Have you had any discussions with [P2] about goals?

OT: Yeah, I’ve spoken to her – um, on this form at the end of it. . . I’ve just gone

through short term and long term goals, and in order to go home she needs to

be able to get in and out of the bath safely to be able to access the shower and

prepare food and meals safely – she’s actually looking at Meals on Wheels.

(Interview with P2’s OT)

Clinical Nurse Leader: We haven’t really made any goals yet for him ‘cause

they’re just assessing him now, [the PT] is just walking him now ‘cause they

were walking him in medical. . . so there’s no input yet, and no goals – we could

make – his wife apparently – ‘cause he’s on thickened –

Registered Nurse: Thickened fluids, yeah

Clinical Nurse Leader: So we could have a goal that he could start you know – a

goal towards feeding himself.

(P1’s first weekly IDT meeting)

PT: If he’s only going to be here for a week, there are a lot of goals that you’re

not going to achieve in a week. Um, yeah, so I’ll probably write down the goals I

think he could achieve in a week.

(Interview with P3’s PT)

OT: See, long term, there’s going to be other issues. . . can [Mary] engage in the

things that she likes to engage in, can she go out of the house, will she be able to

meet her friends?. . .

Researcher: Will you address those issues while she’s in an inpatient setting

here?

OT: Um, less likely to.

Researcher: Why do you think that’s less of a focus?

OT: It, it shouldn’t be, but it’s more um, I just find it’s more, more of a focus to

actually deal with the discharge. . . It’s a time thing and a case load thing pretty

much.

(Interview with P4’s OT)

Physician: So we should have a goal about walking, should we?

PT: Well, I want her to be able to stand first because the problem is as soon as

you take her out of the parallel bars, she falls over, so as long as she’s got both

hands on the parallel bars and she can pull herself forward like this the whole

time, she can walk

Physician: But there’s no – I can’t see any real reason why she shouldn’t be able

to um, to walk eventually

PT: Oh, yeah, eventually. But I kind of, I don’t know how long a timeframe to

put on that, so I’ve just set her the one to stand this week and then if she can

achieve that we should be able to look at walking next week.

Physician: Okay, alright then

(P4’s fifth weekly IDT meeting)

Researcher: So tell me about the process of finding out about her goals now. . .

Nurse: Okay. Um I think she’s quite a straight forward one. . . from dealing with

her this morning, most of the stuff she can basically do herself. So I mean,

toileting she can do it herself once she’s supervised in there and things like

that. So for goal setting. . . I’d be looking at things with her ADLs [activities of

daily living], there’d be ‘with assistance where needed’. But she’d probably be

more minimum, minimal assistance really because she can do just about

everything herself. She just needs like supervision and maybe someone to help

put her socks and shoes on. . . That’s where she’s at at the moment. So that’s

what - I’ll be setting those goals for those sort of things so that’s what I’ll be

going away to do.

(Interview with P5’s Nurse)

W.M.M. Levack et al. / Patient Education and Counseling 85 (2011) 206–213210

goals were already privileged. When there was alignment betweenprivileged goals and the objectives, attitudes and perceivedcapacity of patients and family members, goal setting progressedrelatively smoothly. However, when such alignment was poor,interactional dilemmas emerged for clinicians. In such circum-stances the clinicians employed strategies to navigate their waythrough these dilemmas, while retaining control over theprivileged goals.

3.4. Privileging of goals

The term ‘privileged goals’ was used to describe a conferring ofspecial advantage to certain goals, elevating them in importanceover others in clinical documentation and discussion by the team.Privileged goals in this context tended to display three traits: (1) anorientation towards physical functioning, (2) short timeframes fortheir achievement, and (3) conservative estimates of progress. (SeeTable 2 for examples of each trait.)

Of the 45 IDT goals, 38 related to physical function (e.g.mobility, self-cares, hand function, continence, and basic commu-nication). The remaining seven ‘goals’ described tasks for cliniciansto complete rather than outcomes for patients to achieve. Likewise,35 of the IDT goals were set for completion in one or two weeks,with three other goals set with a three to four week timeframe, andseven goals were set with no stated timeframe.

Interestingly, there was no apparent relationship between thesetting of a goal and the amount of discussion time on particularissues in IDT meetings. Some issues around which no goals wereset (e.g. regarding physiological, psychological, and social func-tioning) were discussed in depth; over several subsequentmeetings.

The dominance of short timeframes and physical function inIDT goals appeared to reflect the clinicians’ overriding sense ofresponsibility to a primary objective: to return the patient to thecommunity as quickly and as safely as possible. (For example, inthe first extract in Table 2, P2’s OT discusses goal setting withreference solely to the performance of daily activities required forliving alone at home.) While clinicians expressed some interest inthe broader aspects of life after stroke, this interest generally didnot extend to the development of targeted goals – an issueidentified by one physician as a limitation of his team’s approach togoal setting:

In order for the process [of goal setting] to work it’s necessaryto bring things down from a long term – what people aregoing to get out of their life kind of level – which is how I liketo see it, down to the nuts and bolts of what is required to getsomebody out of hospital. And clearly it’s possible to use theterm goal planning right down to that level but for me that’sreally more of the issue of task allocation and completion. . .

Because we’re - most of the time we’re uncomfortable withthat sort of rather vague timeframe and having troubledefining what it is that’s – ‘cos it’s not achievable within ahospital stay, almost by definition. And it requires enormousemphasis on psychological health and we’re very uncomfort-able about that too.

[Interview with P7’s physician]

Closely associated with short timeframes was a tendencytowards conservative estimation of progress in the selection of IDTgoals. Clinicians talked about this as the practice of breakingrehabilitation down into small, achievable ‘steps’. Underpinningthis approach were three dominant beliefs: firstly that rehabilita-tion of complex activities is easier if broken down into stages;secondly that rehabilitation needs to occur in a particular order(e.g. patients should regain sitting balance before working on

standing and walking); and thirdly that clinicians need to predictoutcomes with reasonable accuracy, to be able to state in a publicforum (such as an IDT meeting) what was being worked on andwhen it was going to be achieved (see Table 2 for examples). As aconsequence of this third belief, clinicians tended to err on the sideof caution when setting goals in order to ensure that stated goalswould be met. Thus, being realistic when goal setting was highlyvalued; being ambitious regarding goals for rehabilitation wasdiscouraged.

3.5. The borderlands of ‘patient-centered’ goal setting

The second key theme arising from this study related to theunknown and unpredictable nature of conversations with patientsand families when clinicians attempted to engage with them overgoal setting. Privileged goals represented, for clinicians, knownterritory. These goals related to activities that the clinicians werecomfortable performing; which addressed what they believedwere their main work responsibilities. However, the concept of‘privileging’ certain goals seemed at odds with other co-existingvalues held by clinicians in this study; in particular, with the tenetsof ‘patient-centered’ rehabilitation.

So I guess with someone like [P2]. . . she wants to achieve this,she has some time [on the ward] and we work really hard attrying to achieve that. . . I guess because of the goal setting, itbecomes a lot easier and a lot more patient-centered anddirected, yeah.

(Interview with P2’s PT)

The challenge with patient-centered goal setting was that whenpatients (or their family) were asked to state what they wanted toachieve in rehabilitation, their answers were at times unexpectedor not aligned with the type of goals that the clinicians themselvesbelieved should be the focus of rehabilitation. Such conversationshad the potential to become unpredictable, carrying a sense of riskthat patients or family members might raise topics that wereawkward or time consuming for the clinicians to address.

P2: And then another, what I’m going to do is - I can,I can call this a goal - it’d be accurate - but whatI thought I’d like to be in a position to do was geton the Internet

Nurse: Oh, interesting, you’ve got a computer at home?

P2: No, I haven’t. That’s the point

Nurse: Oh, okay

P2: They’re expensive

Nurse: Yeah, they are expensive

P2: Yeah, so –

(P2’s first goal setting meeting)

When interactional dilemmas like this arose, the cliniciansemployed strategies to navigate their way through conversations,back towards more familiar (i.e. privileged) goals. One suchstrategy was simply to ignore stated goals that were deemedoutside the scope of the inpatient rehabilitation. In the case of P2above – a 90 year old woman whose stroke had restricted herpreviously high level of involvement in political activism – a goal toaccess the Internet appeared so far removed from what was ‘usual’inpatient work that the interviewing nurse simply did not seem toconsider the subject relevant to the discussion. Thus this goal neverfeatured on the IDT plan.

Some patient and family goals however were not as easy to justignore. For example, when P1’s wife was interviewed by an

W.M.M. Levack et al. / Patient Education and Counseling 85 (2011) 206–213 211

occupational therapist to make decisions about the selection ofgoals for therapy, she stated that P1’s goals were to address hisdifficulties with vision (for reading), incontinence, swallowing, andsocialization. (P1 himself had very limited capacity to participatein such discussions.) However, the occupational therapist believedit was important to set and prioritize a goal around P1’s ability toshower. Because this goal had not previously been raised by P1 orhis wife, the occupational therapist made several attempts duringthe interview to add it to the agenda. Eventually P1’s wife explicitlydisagreed.

OT: Do you think for him, showering would besomething that he -

Wife: Not important at all, no

OT: No

Wife: He actually prefers a bath. . .

OT: So for him, it’s probably more about thecommunication, and bit or pieces -

Wife: Definitely –

OT: Rather than about – well, he doesn’t mind gettinghelp with a few other things

Wife: No

(P1’s first OT assessment)

Nevertheless, the occupational therapist appeared to remainconvinced that she had a responsibility to address self-careactivities in P1’s IDT plan. P1 appeared likely to need a high-level of attendant care for personal cares on discharge and theIDT would look to the occupational therapist to provide adviceregarding safe management of this. At the end of this discussion,she therefore introduced one final strategy to put showering onthe IDT plan. This involved providing a loose commitment toaddress one of the four ‘patient and family goals’, followed by anauthoritative statement to work on showering regardless. At thispoint in the interaction, P1’s wife relented:

OT: We can maybe - I can talk to the BlindFoundation, see what they’ve got

Wife: That would be brilliant, thanks

OT: Probably would be – work very slowly with thatone, but, you know, not quite yet, but um, yeah– something like that would be good if that, thatwas what he was really keen on. . . and I mightbook in to give him a shower and maybepossibly next week – yeah, maybeearly next week

Wife: Great

OT: And see how he’s going with that

(P1’s first OT assessment)

Another strategy for navigating around such interactionaldilemmas involved prefacing any such discussion with state-ments that indirectly but effectively limited the potential scopeof goals. For instance, clinicians would introduce theseconversations with statements regarding the scope of theirprofessional role or by giving examples of possible goals, but indoing so would emphasize the selection of privileged goals:

OT: So the sorts of things that I look at are the really theday to day activities that people do. So that might behaving a shower, getting dressed, making a meal,getting around your house. A big component of myjob is making sure people are safe in their homeenvironments. So today I wanted to firstly explainmy role. . . and also to set goals with you. . . I know it’sa bit of a - bit of an airy fairy subject for some people,but it is important to know what you want to work on,what you feel you need to achieve. So if you thinkabout how you’re going now, how you’re managingon the ward at the moment, with all of your things likewalking, your personal cares, what do you think youneed to improve on or be doing better?

P6: I don’t know um – balance?

(P6’s first goal setting meeting)

3.6. Impact on delivery of rehabilitation

The theory constructed from this study explained howinteractions between IDTs, patients and family members aremediated in part by the degree of alignment between privilegedgoals and the objectives, attitudes and perceived capacity ofpatients and family members. Interactional dilemmas were thusless likely to occur when patient and family goals focused explicitlyon physical functioning; in areas where clinicians felt gains couldbe made during their period of hospitalization.

Pretty straightforward really, he pretty much tells you what hewants [to return to bowling and to improve manual dexterity]before you even get to asking him really, he knows exactly whathe wants to achieve. . . he has goals that you can directly takeand make into treatments

(Interview with P3’s PT)

However, because privileged goals were associated withconservative estimations of outcome and relatively short time-frames, they tended to describe the rehabilitation process ratherthan drive it. Decisions regarding treatment opinions tended to bemade first before a ‘realistic’ goal was set to reflect these. Therefore,even when patient goals aligned with privileged goals, these did notnecessarily alter the selection of interventions for therapy.

They [the physiotherapists] certainly had an interest in thegame of bowls and the fact that I was you know a bowler andhad bowling as a hobby. . . but they didn’t set any special plan Idon’t feel, to suit a bowling action. . . they studied me – theymade me bring my bowls to the hospital. . . But the exercisesthat I was performing didn’t change, they were the sameexercises prior to them seeing me bowl and they kept up thesame exercises after. They didn’t change them at all.

(Interview with P3, three months after discharge)

Thus goals appeared to have little if any effect on the selectionor delivery of interventions. Goal setting was not used by cliniciansas an activity to influence their own individual behavior orcollective striving, but rather to mark progress along a process thatreflected established clinical roles and perceived resource capacity.

OT: At the moment, like I say, I’m focusing very much onpersonal cares [for P4]. I’m not really looking at the [bed tochair] transfers at this stage actively um, just purely because Isuppose it’s manpower. We need assistance of two to be able todo anything like that [referring to being understaffed at thetime of interview].

(Interview with P4’s OT)

W.M.M. Levack et al. / Patient Education and Counseling 85 (2011) 206–213212

4. Discussion and conclusion

4.1. Discussion

Firstly, the characteristics of the observed ‘privileged goals’were not substantially different from that recommended incurrent rehabilitation guidelines. It is frequently stated forexample that rehabilitation goals should be specific, measurable,activity-related, realistic and time-limited [1,5,27] and certainlythe majority of documented IDT goals in this study met thesecriteria. Nevertheless, a possible criticism of the observedapproach to goal setting could be that despite having processesfor identification of ‘patients and family goals’, the clinicianshad not been sufficiently ‘patient-centered’ in their selectionof which goals to work on. However, it would appear from thisstudy that in inpatient rehabilitation other factors exist thatcompete with and limit the capacity for clinicians to be ‘patient-centered’, even when this approach is desired by cliniciansthemselves.

This finding is consistent with the work of Barnard andcolleagues, who used conversation analysis to examine thenegotiation of rehabilitation goals in six family meetings [23].Barnard et al. found ‘there was rarely a straightforward transla-tion of patient wishes into agreed-upon written goals’ (p. 241)[23]; instead clinicians would use discursive strategies toimplicate patients in therapist-led decisions. Inevitably writtengoals focused on what clinicians deemed to be ‘achievable’ withinthe scope of services they provided. Of note, this finding wasobserved despite Barnard et al.’s qualitative study being nestedwithin a larger clinical trial of a new approach to goal setting – onespecifically designed to enhance greater patient involvement ingoal selection [28].

Historically, goal setting has been presented as a strategy forproblem solving and clinical decision-making [5,29]. What thisresearch suggests is that simply using goal terminology isinsufficient to ensure that documented IDT goals will have anysignificant influence over the rehabilitation process. Other drivers,notably the need to fulfill perceptions of professional obligation(e.g. to ensure patients are as independent as possible withpersonal care) and the need to be responsive to financial andorganizational imperatives (e.g. to discharge people as quickly aspossible to independent community living), appear to have greaterinfluence over clinical decisions than any need to address whatmight be genuinely important in the lives of the people receiving arehabilitation service.

The generalisability of this study is limited to the contexts inwhich data were gathered. The theory constructed during thisstudy is likely to reflect the organization of inpatient rehabilitationfor stroke within New Zealand’s health funding system. AnAustralian study of patient-centered goal setting in community-based rehabilitation for instance was more optimistic regardinghow easy it is to set goals that are personally meaningful to thepeople in those services [3]. Nonetheless, it is noteworthy thatother researchers from other countries have also observed that thenegotiation of goals with patients is challenging and time-consuming [24,30,31] and that clinicians struggle to make goalsset in inpatient environments relevant to the lives of people in thecommunity [2,19,31].

One further limitation of this study was that data were notcollected regarding the specific experience and background of theparticipating clinicians. It is possible that postgraduate trainingand experience could have been a factor that restricted the abilityof these clinicians to act in what might be considered a more‘patient-centered’ manner. Further study however would berequired to determine the effect of training on clinical behaviorin this regard.

4.2. Conclusion

This paper has introduced the notion of the privileging ofcertain goals in inpatient rehabilitation, and has presented asubstantive theory explaining how these privileged goals createinteractional dilemma for clinicians when they do not align withthe objectives, attitudes and perceived capacity of patients andtheir family. The privileging of goals was seen to be driven to alarge degree by financial and organizational factors. This raisesquestions about whether a ‘patient-centered’ approach is evenpossible in inpatient stroke rehabilitation when consideringpredominant funding and health system models.

4.3. Practice implications

In the future, if rehabilitation teams wish to promote a more‘patient-centered’ approach to goal setting, they will need toensure they identify and address barriers to the engagement ingoals deemed important to patients and their family. A clinicalaudit might be of benefit in this regard to examine the types ofgoals that are documented in IDT plans in order to examinewhether the emphasis placed on various aspects of life withdisability is appropriate for the service being provided. However, atruly ‘patient-centered’ approach to rehabilitation may require asignificant shift in the way clinicians think about goal setting andrehabilitation. Clinicians would need to be open to the possibilitythat anything a patient or family member introduces during goalsetting sessions should at least be considered for discussion. Thismight require clinicians to consider topics outside the traditionalscope of inpatient rehabilitation. It may also require clinicians toconsider goals that they deem to be ‘unrealistic’.

Acknowledgements

Financial support for Dr Richard Siegert’s involvement in thepreparation of this manuscript was provided by the DunhillMedical Trust and the Luff Foundation.

Dr Sarah Dean’s position at the Peninsula College of Medicineand Dentistry, University of Exeter is supported through thePeninsula Collaboration for Leadership in Applied Health Researchand Care (PenCLAHRC), funded by the National Institute of HealthResearch, UK.

Kathryn McPherson’s Chair in Rehabilitation is part funded bythe Laura Fergusson Trust (Auckland).

References

[1] Barnes MP, Ward AB. Textbook of rehabilitation medicine. Oxford: OxfordUniversity Press; 2000.

[2] Cott CA. Client-centred rehabilitation: client perspectives. Disabil Rehabil2004;26:1411–22.

[3] Doig E, Fleming J, Cornwell PL, Kuipers P. Qualitative exploration of a client-centered, goal-directed approach to community-based occupational therapyfor adults with traumatic brain injury. Am J Occup Ther 2009;63:559–68.

[4] Randall KE, McEwen IR. Writing patient-centered functional goals. Phys Ther2000;80:1197–203.

[5] Wilson BA. Neuropsychological rehabilitation. Annu Rev Clin Psychol2008;4:141–62.

[6] Levack WMM, Dean S, Siegert RJ, McPherson KM. Purposes and mechanisms ofgoal planning in rehabilitation: the need for a critical distinction. DisabilRehabil 2006;28:741–9.

[7] Levack WMM, Dean SG, McPherson KM, Siegert RJ. How clinicians talk aboutthe application of goal planning to rehabilitation for people with brain injury—variable interpretations of value and purpose. Brain Injury 2006;20:1439–49.

[8] Playford ED, Siegert RJ, Levack W, Freeman J. Areas of consensus and disagree-ment about goal-setting in rehabilitation: a conference report. Clin Rehabil2009;23:334–44.

[9] Siegert RJ, Taylor WJ. Theoretical aspects of goal-setting and motivation inrehabilitation. Disabil Rehabil 2004;26:1–8.

[10] Levack WMM, Taylor K, Siegert RJ, Dean SG, McPherson KM, Weatherall M. Isgoal planning in rehabilitation effective? A systematic review. Clin Rehabil2006;20:739–55.

W.M.M. Levack et al. / Patient Education and Counseling 85 (2011) 206–213 213

[11] Leplege A, Gzil F, Cammelli M, Lefeve C, Pachoud B, Ville I. Person-centred-ness: conceptual and historical perspectives. Disabil Rehabil 2007;29:1555–65.

[12] Mead N, Bower P. Patient-centredness: a conceptual framework and review ofthe empirical literature. Soc Sci Med 2000;51:1087–110.

[13] Lewin S, Skea Z, Entwistle V, Zwarenstein M, Dick J. Interventions for providersto promote a patient-centred approach in clinical consultations. CochraneDatabase Syst Rev 2001;4.

[14] Mead N, Bower P, Hann M. The impact of general practitioners’ patient-centredness on patients’ post-consultation satisfaction and enablement. SocSci Med 2002;55:283–99.

[15] Conneeley AL. Interdisciplinary collaborative goal planning in a post-acuteneurological setting: a qualitative study. Br J Occup Ther 2004;67:248–55.

[16] Holliday RC, Ballinger C, Playford ED. Goal setting in neurological rehabilita-tion: patients perspectives. Disabil Rehabil 2007;29:389–94.

[17] Lawler J, Dowswell G, Hearn J, Forster A, Young J. Recovering from stroke: aqualitative investigation of the role of goal setting in late stroke recovery. J AdvNurs 1999;30:401–9.

[18] McColl MA, Paterson M, Davies D, Doubt L, Law M. Validity and communityutility of the Canadian Occupational Performance Measure. Can J Occup Ther2000;67:22–30.

[19] Playford ED, Dawson L, Limbert V, Smith M, Ward CD, Wells R. Goal-setting inrehabilitation: report of a workshop to explore professionals’ perceptions ofgoal-setting. Clin Rehabil 2000;14:491–6.

[20] Schulman-Green DJ, Naik AD, Bradley EH, McCorkle R, Bogardus ST. Goalsetting as a shared decision making strategy among clinicians and their olderpatients. Patient Educ Couns 2006;63:145–51.

[21] Wottrich AW, Stenstrom CH, Engard M, Tham K, Von Koch L. Characteristics ofphysiotherapy sessions from the patient’s and therapist’s perspective. DisabilRehabil 2004;26:1198–205.

[22] Wressle E, Lindstrand J, Neher M, Marcusson J, Henriksson C. The CanadianOccupational Performance Measure as an outcome measure and team tool in aday treatment programme. Disabil Rehabil 2003;25:497–506.

[23] Barnard RA, Cruice MN, Playford ED. Strategies used in the pursuit of achiev-ability during goal setting in rehabilitation. Qual Health Res 2010;20:239–50.

[24] Parry RH. Communication during goal-setting in physiotherapy treatmentsessions. Clin Rehabil 2004;18:668–82.

[25] Charmaz K. Constructing grounded theory. London: Sage Publications Ltd.; 2006.[26] Morse JM, Richards L. Readme first for a user’s guide to qualitative methods.

Thousand Oaks: Sage Publications Inc.; 2002.[27] Marsland E, Bowman J. An interactive education session and follow-up sup-

port as a strategy to improve clinicians’ goal-writing skills: a randomizedcontrolled trial. J Eval Clin Pract 2010;16:3–13.

[28] Holliday RC, Cano S, Freeman JA, Playford ED. Should patients participate inclinical decision making? An optimised balance block design controlled studyof goal setting in a rehabilitation unit. J Neurol Neurosurg Psychiatry 2007;78:576–80.

[29] McGrath JR, Davis AM. Rehabilitation: where are we going and how do we getthere? Clin Rehabil 1992;6:225–35.

[30] Schoeb V. The goal is to be more flexible’’—detailed analysis of goal setting inphysiotherapy using a conversation analytic approach. Manual Ther 2009;14:665–70.

[31] Leach E, Cornwell P, Fleming J, Haines T. Patient centered goal-setting in asubacute rehabilitation setting. Disabil Rehabil 2010;32:159–72.