“The goal is to be more flexible” – Detailed analysis of goal setting in physiotherapy using a conversation analytic approach

Utilising patient-reported outcomes for goal-directed therapy of hip fracture patients: a sequential controlled trial

BACKGROUND

Hip fracture patients (HFPs) frequently have multiple underlying conditions, necessitating that agreed-upon goals take these complications into consideration. Communication regarding goals between medical-personnel and patients is not always effective. Patient-reported outcomes (PROs) can outline personal goals and help promote quality health care in HFPs. Few studies have been published on this topic. The study's aim was to outline the process of using PROs for goal-directed therapy among HFPs.

METHODS

This sequential controlled trial was conducted among HFPs from two medical centres. The control and the intervention group received integrative rehabilitation. PROs were measured in both groups using the SF36 questionnaire three times postsurgery: 24-48 hours, 2 weeks and 3 months. During the first round of questioning, only the intervention group was asked 'what matters most to you?' during the rehabilitative process. Accordingly, agreed-upon goals that were determined by the SF36's eight topics and were incorporated into the HFP's rehabilitative process. A Likert scale of 1-5, '1' indicating no-achievement and '5' full-achievement, was used to assess the goal achievement 4-6 months post-fracture.

RESULTS

84 HFPs participated in the study: 40 and 44 in the intervention and control group, respectively. In both groups, PROs declined after the HF, then improved somewhat 3 months later, but did not return to prefracture scores. Among the intervention group, 39% reached their specific goals (Likert level 5). Patients who achieved their goals had better PROs in comparison to others. The intervention group indicated PROs helped them articulate their desires and introduced them to new areas of care.

CONCLUSIONS

Shifting from asking 'what's the matter?' to 'what matters most to you?' can improve the understanding of HFPs' own priorities, promote quality outcomes and enhance patient-centred care. Using PROs as a guide for goal-directed therapy can create a more inclusive process that includes the patients' most important health determinants and needs.

Goal setting in physiotherapy-led adult musculoskeletal care: A scoping review

INTRODUCTION

Goal setting is a key part of rehabilitation across various fields of physiotherapy. It is less clear what evidence exists to underpin its effectiveness and to practically guide its use within musculoskeletal physiotherapy.

OBJECTIVES

This scoping review provides an overview of current research regarding goal setting in adult physiotherapy-led musculoskeletal care with three aims: 1) to identify and analyse any gaps in the literature, 2) to identify relevant features of goal setting theory and 3) to make recommendations for future research. The principal research question was what does the literature tell us about the role of goal setting for adults over the age of 18 with musculoskeletal pain accessing outpatient physiotherapy services?

INCLUSION CRITERIA

The population, concept and context framework was used to define the inclusion criteria. Key definitions were adults over the age of 18 with musculoskeletal conditions, goal setting, and physiotherapy-led interventions.

METHODS

This scoping review followed the guidance set out by the Joanna Briggs Institute Manual for Evidence Synthesis. Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature Plus with Full Text, MEDLINE, American Psychological Association PsycInfo and the Cochrane Database of Systematic Reviews, Protocols and Trials were searched using pre-defined search criteria. Data were extracted from screened full-text articles and presented in basic statistical and narrative form.

RESULTS

41 articles were included in the review. Several broad themes and research methods were identified. The nature of the studies suggested that the clinical application of goal setting is complex and the depth of understanding is limited. Most studies suggested that goal setting is feasible and has a positive impact on outcomes. A common finding was a lack of clear definitions regarding goal setting terminology and approaches. Study samples were generally defined by biomedical categories, suggesting a pathoanatomical approach to researching a cognitive construct. Theoretical underpinning was lacking in many studies. No frameworks guiding goal setting in physiotherapy-led musculoskeletal rehabilitation have been identified.

CONCLUSIONS

Goal setting is a popular tool within musculoskeletal outpatient physiotherapy. Further research is required to clarify its efficacy and provide guidance on its role and application in clinical practice.

Approaches to tracheoesophageal voice rehabilitation: a survey of the UK and Irish speech and language therapists' current practice and beliefs

BACKGROUND

After total laryngectomy, surgical voice restoration is used to establish communication via tracheoesophageal voice prosthesis. Once voice is established, there is a paucity of information on what speech and language therapists (SLTs) should do to improve tracheoesophageal voice quality to ensure functional communication. No existing surveys or studies investigate this specific question. There is also a disconnect between guidelines, knowledge and clinical practice, whereby clinical guidelines stipulate the requirement for SLT intervention, but do not detail what this entails in the rehabilitation context.

AIMS

(1) To advance understanding of current clinical practice beyond voice prosthesis management and care. (2) To explore what approaches are implemented in clinical practice across the UK and Republic of Ireland to rehabilitate tracheoesophageal voice. (3) To investigate the barriers and facilitators to provision of tracheoesophageal voice therapy.

METHODS & PROCEDURES

A self-administered 10-min online survey was developed using Qualtrics software and piloted before dissemination. Survey development was informed by the Behaviour Change Wheel to identify barriers, facilitators and additional factors contributing to SLTs' provision of voice therapy to tracheoesophageal speakers. The survey was disseminated via social media and professional networks. Eligibility criteria included SLTs with at least one year post-registration experience and with experience of working with laryngectomy in the past 5 years. Descriptive statistics were used to analyse closed answer questions. Open question responses were analysed using content analysis.

OUTCOMES & RESULTS

The survey received 147 responses. Participants were representative of the head and neck cancer SLT workforce. SLTs believe that tracheoesophageal voice therapy is an important aspect of laryngectomy rehabilitation; however, there was a lack of knowledge about therapy approaches and insufficient resources for implementing therapy. SLTs expressed a desire for more training, specific guidelines and a stronger evidence base to inform clinical practice. Some SLTs expressed feelings of frustration and lack of acknowledgement for the specialist skills required to undertake laryngectomy rehabilitation and tracheoesophageal work in general.

CONCLUSIONS & IMPLICATIONS

The survey identifies the need for a robust training approach and detailed clinical guidelines to promote consistent practice across the profession. The evidence base within this clinical area is emergent, hence there is a need for increased research and clinical audit to inform practice. Under-resourcing was highlighted, which should be considered in service planning to ensure that adequate staff, access to expert practitioners or time ring-fenced for therapy are available for tracheoesophageal speakers to receive the support they require.

WHAT THIS PAPER ADDS

What is already known on this subject Total laryngectomy results in life-altering changes to communication. Clinical guidelines advocate for speech and language therapy intervention; however, there is no clear information on what SLTs should do to optimize tracheoesophageal voice and the evidence base to support practice is lacking. What this study adds to existing knowledge This survey identifies what interventions SLTs provide in clinical practice to rehabilitate tracheoesophageal voice; and it explores the barriers and facilitators that influence the provision of tracheoesophageal voice therapy. What are the potential or actual clinical implications of this work? Specific training, clinical guidelines, increased research and audit are required to support clinical practice in laryngectomy rehabilitation. Service planning should address the under-resourcing of staff, expert practitioners and therapy allocated time.

Patient-Centered Goals After Lumbar Spine Surgery: A Secondary Analysis of Cognitive-Behavioral-Based Physical Therapy Outcomes From a Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to examine the association between goal attainment and patient-reported outcomes in patients who engaged in a 6-session, telephone-based, cognitive-behavioral-based physical therapy (CBPT) intervention after spine surgery.

METHODS

In this secondary analysis of a randomized trial, data from 112 participants (mean age = 63.3 [SD = 11.2] years; 57 [51%] women) who attended at least 2 CBPT sessions (median = 6 [range = 2-6]) were examined. At each session, participants set weekly goals and used goal attainment scaling (GAS) to report goal attainment from the previous session. The number and type of goals and percentage of goals met were tracked. An individual GAS t score was computed across sessions. Participants were categorized based on goals met as expected (GAS t score ≥ 50) or goals not met as expected (GAS t score < 50). Six- and 12-month outcomes included disability (Oswestry Disability Index), physical and mental health (12-Item Short-Form Health Survey), physical function (Patient-Reported Outcomes Measurement Information System), pain interference (Patient-Reported Outcomes Measurement Information System), and back and leg pain intensity (numeric rating scale). Outcome differences over time between groups were examined with mixed-effects regression.

RESULTS

Participants set a median of 3 goals (range = 1-6) at each session. The most common goal categories were recreational/physical activity (36%), adopting a CBPT strategy (28%), exercising (11%), and performing activities of daily living (11%). Forty-eight participants (43%) met their goals as expected. Participants who met their goals as expected had greater physical function improvement at 6 months (estimate = 3.7; 95% CI = 1.0 to 6.5) and 12 months (estimate = 2.8; 95% CI = 0.04 to 5.6). No other outcome differences were noted.

CONCLUSIONS

Goal attainment within a CBPT program was associated with 6- and 12-month improvements in postoperative physical functioning.

IMPACT

This study highlights goal attainment as an important rehabilitation component related to physical function recovery after spine surgery.

Ready for goal setting? Process evaluation of a patient-specific goal-setting method in physiotherapy

Background

Patient participation and goal setting appear to be difficult in daily physiotherapy practice, and practical methods are lacking. An existing patient-specific instrument, Patient-Specific Complaints (PSC), was therefore optimized into a new Patient Specific Goal-setting method (PSG). The aims of this study were to examine the feasibility of the PSG in daily physiotherapy practice, and to explore the potential impact of the new method.

Methods

We conducted a process evaluation within a non-controlled intervention study. Community-based physiotherapists were instructed on how to work with the PSG in three group training sessions. The PSG is a six-step method embedded across the physiotherapy process, in which patients are stimulated to participate in the goal-setting process by: identifying problematic activities, prioritizing them, scoring their abilities, setting goals, planning and evaluating. Quantitative and qualitative data were collected among patients and physiotherapists by recording consultations and assessing patient files, questionnaires and written reflection reports.

Results

Data were collected from 51 physiotherapists and 218 patients, and 38 recordings and 219 patient files were analysed. The PSG steps were performed as intended, but the ‘setting goals’ and ‘planning treatment’ steps were not performed in detail. The patients and physiotherapists were positive about the method, and the physiotherapists perceived increased patient participation. They became aware of the importance of engaging patients in a dialogue, instead of focusing on gathering information. The lack of integration in the electronic patient system was a major barrier for optimal use in practice. Although the self-reported actual use of the PSG, i.e. informing and involving patients, and client-centred competences had improved, this was not completely confirmed by the objectively observed behaviour.

Conclusion

The PSG is a feasible method and tends to have impact on increasing patient participation in the goal-setting process. However, its full potential for shared goal setting has not been utilized yet. More implementation effort is needed to achieve the required behaviour change and a truly client-centred attitude, to make physiotherapists totally ready for shared goal setting.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2557-9) contains supplementary material, which is available to authorized users.

Communication practices that encourage and constrain shared decision making in health-care encounters: Systematic review of conversation analytic research

Background

Shared decision making (SDM) is generally treated as good practice in health‐care interactions. Conversation analytic research has yielded detailed findings about decision making in health‐care encounters.

Objective

To map decision making communication practices relevant to health‐care outcomes in face‐to‐face interactions yielded by prior conversation analyses, and to examine their function in relation to SDM.

Search strategy

We searched nine electronic databases (last search November 2016) and our own and other academics' collections.

Inclusion criteria

Published conversation analyses (no restriction on publication dates) using recordings of health‐care encounters in English where the patient (and/or companion) was present and where the data and analysis focused on health/illness‐related decision making.

Data extraction and synthesis

We extracted study characteristics, aims, findings relating to communication practices, how these functioned in relation to SDM, and internal/external validity issues. We synthesised findings aggregatively.

Results

Twenty‐eight publications met the inclusion criteria. We sorted findings into 13 types of communication practices and organized these in relation to four elements of decision‐making sequences: (i) broaching decision making; (ii) putting forward a course of action; (iii) committing or not (to the action put forward); and (iv) HCPs' responses to patients' resistance or withholding of commitment. Patients have limited opportunities to influence decision making. HCPs' practices may constrain or encourage this participation.

Conclusions

Patients, companions and HCPs together treat and undertake decision making as shared, though to varying degrees. Even for non‐negotiable treatment trajectories, the spirit of SDM can be invoked through practices that encourage participation (eg by bringing the patient towards shared understanding of the decision's rationale).

The development of a patient-specific method for physiotherapy goal setting: a user-centered design

PURPOSE

To deliver client-centered care, physiotherapists need to identify the patients' individual treatment goals. However, practical tools for involving patients in goal setting are lacking. The purpose of this study was to improve the frequently used Patient-Specific Complaints instrument in Dutch physiotherapy, and to develop it into a feasible method to improve physiotherapy goal setting.

METHODS

An iterative user-centered design was conducted in co-creation with the physiotherapists and patients, in three phases. Their needs and preferences were identified by means of group meetings and questionnaires. The new method was tested in several field tests in physiotherapy practices.

RESULTS

Four main objectives for improvement were formulated: clear instructions for the administration procedure, targeted use across the physiotherapy process, client-activating communication skills, and a client-centered attitude of the physiotherapist. A theoretical goal-setting framework and elements of shared decision making were integrated into the new-called, Patient-Specific Goal-setting method, together with a practical training course.

CONCLUSIONS

The user-centered approach resulted in a goal-setting method that is fully integrated in the physiotherapy process. The new goal-setting method contributes to a more structured approach to goal setting and enables patient participation and goal-oriented physiotherapy. Before large-scale implementation, its feasibility in physiotherapy practice needs to be investigated. Implications for rehabilitation Involving patients and physiotherapists in the development and testing of a goal-setting method, increases the likelihood of its feasibility in practice. The integration of a goal-setting method into the physiotherapy process offers the opportunity to focus more fully on the patient's goals. Patients should be informed about the aim of every step of the goal-setting process in order to increase their awareness and involvement. Training physiotherapists to use a patient-specific method for goal setting is crucial for a correct application.

The use and perceived usefulness of a patient-specific measurement instrument in physiotherapy goal setting. A qualitative study

OBJECTIVES

Physiotherapists are encouraged to set goals together with their patients to deliver client-centred care. In practice however, this goal-setting process is poorly specified, with limited patient involvement. The Patient-Specific Complaints instrument (PSC) can support the goal-setting process. Despite its being frequently used by Dutch physiotherapists, its actual role in goal setting is unknown. The objective was to examine physiotherapy goal-setting and the use of the PSC within this process, as well as the physiotherapists' perception of the usefulness of the PSC.

METHODS

Consultations between physiotherapists and patients were observed and physiotherapists were interviewed. Data were analysed by directed content analysis, using a goal-setting framework as the coding scheme whose phases include: goal negotiation, goal setting, planning, and appraisal and feedback.

RESULTS

The patients' problems were comprehensively explored, with the PSC focussing on activity problems. Goal-setting and planning phases were poorly specified and mainly physiotherapist-led. The physiotherapists appreciated the PSC for patient involvement during goal negotiation and evaluation. Its perceived usefulness for goal setting and planning ranged from useful for tailoring goals to the patient's needs to not useful at all. One major reason to use it was meeting external audit obligations.

CONCLUSIONS

There are some discrepancies between how physiotherapists use the PSC and how they perceived its usefulness. Physiotherapists did use the PSC in a goal-setting process, though often as a standalone tool without integration in the whole physiotherapy process, and with limited patient involvement. In this way, its full potential for goal setting is not utilized.

The patient's perspective of the feasibility of a patient-specific instrument in physiotherapy goal setting: a qualitative study

BACKGROUND

Patient participation in goal setting is important to deliver client-centered care. In daily practice, however, patient involvement in goal setting is not optimal. Patient-specific instruments, such as the Patient Specific Complaints (PSC) instrument, can support the goal-setting process because patients can identify and rate their own problems. The aim of this study is to explore patients' experiences with the feasibility of the PSC, in the physiotherapy goal setting.

METHOD

We performed a qualitative study. Data were collected by observations of physiotherapy sessions (n=23) and through interviews with patients (n=23) with chronic conditions in physiotherapy practices. Data were analyzed using directed content analysis.

RESULTS

The PSC was used at different moments and in different ways. Two feasibility themes were analyzed. First was the perceived ambiguity with the process of administration: patients perceived a broad range of experiences, such as emotional and supportive, as well as feeling a type of uncomfortableness. The second was the perceived usefulness: patients found the PSC useful for themselves - to increase awareness and motivation and to inform the physiotherapist - as well as being useful for the physiotherapist - to determine appropriate treatment for their personal needs. Some patients did not perceive any usefulness and were not aware of any relation with their treatment. Patients with a more positive attitude toward questionnaires, patients with an active role, and health-literate patients appreciated the PSC and felt facilitated by it. Patients who lacked these attributes did not fully understand the PSC's process or purpose and let the physiotherapist take the lead.

CONCLUSION

The PSC is a feasible tool to support patient participation in the physiotherapy goal setting. However, in the daily use of the PSC, patients are not always fully involved and informed. Patients reported varied experiences related to their personal attributes and modes of administration. This means that the PSC cannot be used in the same way in every patient. It is perfectly suited to use in a dialogue manner, which makes it very suitable to improve goal setting within client-centered care.

Communication during goal-setting in brain injury rehabilitation: What helps and what hinders?

Introduction

Setting goals with individuals with acquired brain injury may be challenging due to impairments in cognition and communication. The purpose of this study was to explore how occupational therapists' communication behaviours during goal-setting with individuals with traumatic brain injury facilitated and hindered this process.

Method

This exploratory study used a conversation analysis inspired approach and frequency calculations to analyse and interpret videotaped goal-setting sessions. Sequences of dialogue leading to, and distracting from, problem identification, a key step in goal-setting, were identified and analysed. Specific therapist behaviours that facilitated or hindered problem identification were subsequently distinguished.

Results

Acknowledgements and affirmations, open-ended questions about specific tasks and reflective listening, were found to lead to problem identification by the client (facilitators). Instances of disconnections were characterized by a single theme, ‘lack of uptake.' Examples of these hindrances to goal-setting included, abrupt topic shifts, lack of acknowlegement and failure to explore what the client said.

Conclusion

Clinicians should consider their language use during goal-setting interviews and aim to utilize conversational behaviours that are facilitative whilst minimizing those that distract to optimize their client's engagement during the problem identification phase of goal-setting.

Musculoskeletal physiotherapists' use of psychological interventions: a systematic review of therapists' perceptions and practice

BACKGROUND

Research has demonstrated that incorporating psychological interventions within physiotherapy practice has numerous potential benefits. Despite this physiotherapists have reported feeling inadequately trained to confidently use such interventions in their day-to-day practice.

OBJECTIVE

To systematically review musculoskeletal physiotherapists' perceptions regarding the use of psychological interventions within physiotherapy practice.

DATA SOURCES

Eligible studies were identified through a rigorous search of AMED, CINAHL, EMBASE, MEDLINE and PsychINFO from January 2002 until August 2013.

STUDY ELIGIBILITY CRITERIA

Full text qualitative, quantitative and mixed methodology studies published in English language investigating musculoskeletal physiotherapists' perceptions regarding their use of psychological interventions within physiotherapy practice.

STUDY SYNTHESIS AND APPRAISAL

Included studies were appraised for risk of bias using the Critical Appraisal Skills Programme qualitative checklist. Meta-analysis was not possible due to study heterogeneity.

RESULTS

Six studies, all with a low risk of bias, met the inclusion criteria. These studies highlighted that physiotherapists appreciate the importance of using psychological interventions within their practice, but report inadequate understanding and consequent underutilisation of these interventions.

LIMITATIONS

These results should be noted with some degree of caution due to various limitations associated with the included studies and with this review, including the use of a qualitative appraisal tool for mixed methodology/quantitative studies.

CONCLUSION

These findings suggest that musculoskeletal physiotherapists are aware of the potential benefits of incorporating psychological interventions within their practice but feel insufficiently trained to optimise their use of such interventions; hence highlighting a need for further research in this area and a review of physiotherapist training.

Self-management goal setting: identifying the practice patterns of community-based physical therapists

PURPOSE

To describe the collaborative goal-setting practices of community-based physical therapists trained in a self-management (SM) approach who work with clients with chronic conditions and to describe clients' goal-achievement rates. Methods : A retrospective chart review was conducted for 296 randomly selected home-care clients from July 2009 through July 2010 using a chart-abstraction form created to capture demographic data and information related to goal setting and achievement. Data were analyzed using frequencies, percentages, and Pearson's chi-square tests.

RESULTS

There was no significant relationship between sex, age, or number of chronic conditions and setting SM or non-self-management (NSM) goals or the type of SM goal set. The majority of goals set were "action" as opposed to "verbal" goals. A high proportion (89-100%) of both SM and NSM goals were met.

CONCLUSIONS

Clinicians should be aware that it is possible to set SM goals regardless of the client's sex, age, or number of chronic conditions. Other possible influences on goal setting, such as severity of chronic conditions and challenges of the health care system, should be further investigated.

The use of patient-specific measurement instruments in the process of goal-setting: a systematic review of available instruments and their feasibility

OBJECTIVE

The aim of this study was to identify the currently available patient-specific measurement instruments used in the process of goal-setting and to assess their feasibility.

METHODS

After a systematic search in PubMed, EMBASE, CINAHL, PsychINFO and REHABDATA, patient-specific instruments were included, structured in a goal-setting practice framework and subjected to a qualitative thematic analysis of feasibility.

RESULTS

A total of 25 patient-specific instruments were identified and 11 were included. These instruments can be used for goal negotiation, goal-setting and evaluation. Each instrument has its own strengths and weaknesses during the different phases of the goal-setting process. Objective feasibility data were revealed for all instruments such as administration time, instruction, training and availability. Subjective feasibility could only be analysed for the Canadian Occupational Performance Measure, Goal Attainment Scaling, Self-Identified Goal Assessment and Talking Mats. Relevant themes were that Canadian Occupational Performance Measure and Goal Attainment Scaling were time consuming and difficult for patients with cognitive problems, but they facilitated goal-setting in a client-centred approach. Talking Mats was especially feasible for patients with cognitive and communication impairments.

CONCLUSIONS

A total of 11 instruments were identified, and although some had strong points, there is no single good instrument that can be recommended specifically. Applying a combination of the strengths of the available instruments within a goal-setting framework can improve goal setting and tailor it to individual patients.

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

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.

"Well it has to be language-related": speech-language pathologists' goals for people with aphasia and their families

Goal-setting is considered an essential part of rehabilitation practice and integral to person-centredness. However, people with aphasia are not always satisfied with goal-setting, and speech-language pathologists are concerned about the appropriateness of therapy. Furthermore, family members are often excluded from goal-setting, despite the impact aphasia has on them. The actual goals set by clinicians for clients with aphasia and their family members have not yet been investigated. This study aimed to examine the goals that clinicians set for their clients with aphasia and their family members. Data from in-depth interviews with 34 speech-language pathologists describing 84 goal-setting experiences with people with aphasia were coded into superordinate goals for both groups. Clinicians expressed a wide range of goals for people with aphasia and their family members, relating to communication, coping and participation factors, and education. In addition, evaluation was considered a goal for the clients. There were clients for whom no goals were set, particularly for family members, due to a lack of/limited contact. The goals described broadly addressed all aspects of the International Classification of Functioning, Disability and Health (ICF) and reflected the use of both functional and impairment-based therapeutic approaches; they also emphasize the importance of providing goal-setting options for the family members of these clients.