Goal‐setting in geriatric rehabilitation: Can the nursing profession meet patients' needs? A narrative review

Abstract

Study Objective

To provide an overview of patients' needs concerning goal‐setting, and indications of how those needs can be met by nurses.

Methods

A narrative review. Pubmed and Cinahl were searched through March 1, 2020 for: patients' experiences concerning goal‐setting and the role of nursing in rehabilitation. Additional articles were found through snowballing. A total of 22 articles were reviewed on patients' experiences, and 12 on the nursing role.

Results

Patients need to be prepared for collaborating in goal‐setting and to receive an explanation about their part in that process. The multiplicity of disciplines may cloud patients' understanding of the process. The nurse's planning of the rehabilitation process should be aimed at resolving this issue. Goals need to be meaningful, and patients need support in attaining them. The interpretive, integrative, and consoling functions of Kirkevold's nursing role are suitable to meet these needs.

Conclusions

Both the literature about patients' needs regarding goal‐setting and the nursing role make clear that the way nurses work in rehabilitation can gain in clarity.

Strengthening the role of nurses will improve the goal‐setting process for patients. Interprofessional collaboration, clear work procedures, continuity of care, time and trust, and the physical environment all are important to reinforce this role.

KEY PRACTICE POINTS

• Goals should be personally meaningful for each patient.

• Patients need information about the process of goal‐setting to effectively work on their return home.

• The multiplicity of disciplines may cloud patients' understanding of the process.

• The nurse's planning and coordinating of the rehabilitation process should be executed not just to structure their own work, but for the benefit of the patient's understanding of the process.

• Talking about and being occupied with goals should determine the daily routine in geriatric rehabilitation.

• Through their interpretive, integrative, and consoling function, nurses can play a key role in guiding patients in goal‐setting and goal‐achieving.

1. INTRODUCTION

Geriatric rehabilitation is a relatively new field in health care, aimed at persons over the age of 70 who still desire independence following a medical event, such as a hip fracture or stroke.¹ This fierce desire to be autonomous is evident in persons in many European countries and beyond. In the Netherlands alone, 52,000 people (of a population of 17 million) received geriatric rehabilitation in 2018.² International statistics are unavailable but there is ample reason to suspect similar numbers in various countries.

The prerequisites for geriatric rehabilitation are not dissimilar to those for rehabilitation as a specialized field. The general focus of rehabilitation is also to improve ADL functions and social engagement/participation, and to improve the overall quality of life and wellbeing of those needing these services. In geriatric rehabilitation, the health team addresses multimorbidities, delirium, and other complicating aspects of life, such as fragility, cognitive impairments, continence, gait, and balance problems.^{3, 4}

A vital aspect of rehabilitation is to align the professional expertise of multiprofessional providers with the goals and life aspirations and capacity of the person needing rehabilitation. Without this shared purpose, the feasibility of optimizing the patient's experience will fall short, resources will be squandered, and outcomes diminished.^{5, 6, 7, 8, 9} However, practicing patient‐centered goal‐setting remains a challenge.^{7, 8, 10, 11, 12, 13} Smit et al.¹⁴ tested the feasibility of a new patient‐centered goal‐setting method for geriatric rehabilitation. They found that patients experienced that professionals determine the steps toward the discharge, and these steps were often not clear or transparent to them. To improve the collaboration process on goal‐setting and goal‐achieving and to increase patient participation and motivation, more knowledge is needed about patients' experiences and views of goal‐setting and achieving. This information will help clarify the needs of patients with regard to working on goal‐setting.

Further, the roles and functions of the nurses who intersect and integrate their practice within health disciplines that have less broad‐based purposes is also unclear.^{15, 16} Nurses experience a certain apprehensiveness about performing their tasks in the multidisciplinary team.¹¹ This can be due to absence of clear working procedures, lack of specific knowledge of frail elderly people, the variability of interdisciplinary teamwork and communication, or to patients' expectations that they be cared for instead of supported to practice self‐care.^{11, 15}

The twofold aim of this literature review is to analyze goal‐setting and achievement from the vantage of the patient, with the specific aim of examining nursing roles in the process. Knowledge about this aspect of nursing care could strengthen the role of the nursing profession in geriatric rehabilitation and thus improve the goal‐setting process for patients.

2. METHODS

A narrative review was performed following the General framework of narrative reviews by Ferrari,¹⁷ first focusing on the international literature on patients' perceptions of goal‐setting, and secondly on the nursing role concerning goal‐setting in rehabilitation. To find relevant literature, we searched the databases Pubmed and Cinahl. The terms used in the search for patients' perceptions of goal‐setting were goal setting, goal attaining, geriatric rehabilitation, and patients' experiences. The terms used in the search about the nursing role were nursing role, goal‐setting and geriatric rehabilitation.

In both searches a substantial amount of articles were found through snowballing,¹⁸ which refers to using the reference list of a paper, the citations to the paper or the assigned keywords.¹⁹ One of the main reasons for this is that geriatric rehabilitation is a relatively new field in health care, and not a widely used concept internationally. We also added articles pointed out by colleague researchers. A key article was that of Smit et al.¹⁴ Because Smit et al.¹⁴ tested a method for goal‐setting in geriatric rehabilitation, their paper was useful in the context of the first subject (patients' needs concerning goal‐setting in geriatric rehabilitation). This article in particular led to relevant further articles. The same applies to the article of Loft et al.¹⁶: they studied the self‐perceived outcome of an educational program for nurses on goal‐setting, and gave insight into nurses' perceptions about their role in goal‐setting.

A total of 22 articles on patients' experiences concerning goal‐setting were reviewed (see Table 1). A total of 12 articles on the nursing role in geriatric rehabilitation were reviewed (see Table 2). Both the searches were completed on March 1, 2020.

Table 1.

Studies on patients' experiences included in the review

Authors	The objective of the study	Method	Participants	Setting
Davis (2007)5 USA	To explore goal‐setting and its influence on exercise motivation of people with COPD.	Assessment of motivation and goal orientation. Qualitative study (interviews about exercise and activity goals).	14 patients, mean age 69.7	Community pulmonary clinics rehabilitation centers
Levack et al. (2006)6 New Zealand	To determine the evidence regarding the effectiveness of goal planning in clinical rehabilitation.	Systematic review of 19 studies.	No	Rehabilitation
Plant et al. (2016)7 UK	To identify barriers and facilitators to goal‐setting during rehabilitation for stroke and other acquired brain injuries.	Systematic review and meta‐synthesis of 9 studies.	88 patients Stroke and other acquired brain injuries 25 relatives	Rehabilitation for stroke and other acquired brain injuries
Rose et al. (2019)8 UK	To synthesize literature that considers the extent of shared decision making within goal‐setting in rehabilitation settings, and explore participants' views of this approach within goal‐setting.	Systematic review of 15 studies.	No	Rehabilitation setting
Turner‐Stokes et al. (2015)9 UK	To examine the relationship between patient/family engagement in goal planning, satisfaction with the goal‐setting process, and associated goal attainment and functional gains during rehabilitation.	Prospective cohort analysis of consecutively completed episodes for patients discharged over 1 year.	83 adults with neurological disabilities Mean age 42.8	Specialist neurological rehabilitation service
Cameron et al. (2018)10 Australia	To explore the ways clinicians engage rehabilitation patients in patient‐centered goal‐setting, and identify factors influencing the goal‐setting process.	Qualitative study (transcripts of goal‐setting interviews, focus groups).	17 rehabilitation patients (stroke, amputation, postorthopedic surgery, acquired brain injury) Mean age 57.6	Three general rehabilitation units
Rosewilliam et al. (2011)12 UK	To map out from the literature the nature, extent, and effects of the application of patient‐centered goal‐setting in stroke rehabilitation practice.	Systematic review and synthesis of the qualitative (18) and quantitative (8) and mixed‐method (1) evidence behind patient‐centered goal‐setting.	No	Stroke rehabilitation
Sugavanam et al. (2013)13 UK	To systematically integrate and appraise the evidence for the effects and experiences of goal‐setting in stroke rehabilitation.	Systematic review of 17 studies.	No	Stroke rehabilitation
Smit et al. (2018)14 The Netherlands	To explore the feasibility of Collaborative Functional Goal‐setting (CFGS), i.e., using standardized functional measures to set and evaluate functional goals during geriatric rehabilitation.	Qualitative study (three medical professionals working in two geriatric rehabilitation wards were trained in CFGS. Both patients and professionals were interviewed at the end of the study).	8 patients, mean age 77.	Two geriatric rehabilitation wards
Brown et al. (2014)20 New Zealand	To explore patient experiences of goal‐setting, to further understanding of its application in practice.	Qualitative study (semi‐structured interviews).	10 patients Mean age 59	Postacute stroke rehabilitation in four hospital‐based multidisciplinary rehabilitation teams
Van Seben et al. (2019)21 The Netherlands	To characterize how the rehabilitation goals of older patients change over time and to explore professionals' attitudes toward patient‐centered goal‐setting and their perspectives on rehabilitation goals.	Qualitative study.	10 patients >80, Cardiovascular disease and fractures, 7 professionals.	Three geriatric rehabilitation centers
Playford et al. (2000)22 UK	To explore the views of therapists, nurses and doctors working in a variety of rehabilitation settings on the goal‐setting process.	Qualitative study (a goal‐setting workshop).	16 rehabilitation staff	Neurological rehabilitation unit, community stroke rehabilitation team, department of health care of the elderly
Timmermans et al. (2009)23 The Netherlands	An inquiry into skill preferences of persons after stroke regarding arm‐hand training and examining the relationship between the use of the affected arm and the patient's training preference.	Cross‐sectional survey involving a semi‐structured interview.	20 patients in the subacute stage after stroke, 20 patients in the chronic stage after stroke. Mean age 61	Rehabilitation center
Van de Weyer et al. (2010) 24 UK	To explore rehabilitation professionals' perspectives about goal‐setting, and the use of two specific forms of goal‐setting used within the same setting; “usual participation” and “increased participation.”	Qualitative study (focus group interviews).	15 rehabilitation professionals representing five different professions (speech and language therapist, occupational therapist, physiotherapist, nurse, doctor, student (occupational therapist).	Neurological rehabilitation unit
Rosewilliam et al. (2016)25 UK	To explore whether goal‐setting for rehabilitation with acute stroke survivors is patient‐centered, and identify factors that influence the adoption of patient‐centeredness in goal‐setting practice.	Qualitative study (multiple methods).	7 patients, mean age 64.	Specialized stroke ward
Rose et al. (2017)26 UK	To assess the extent of shared decision making (SDM) within goal‐setting meetings, and explore patient‐reported factors that influenced their participation in SDM about their goals.	Quantitative study (data collection with a multifocal approach to sharing in shared decision making (MAPPIN'SDM) questionnaire, shared decision making rated by an observer, patients and staff and compared, semi‐structured interviews).	40 patients, mean age 83. Frailty syndrome as defined by British Geriatric Society	Two intermediate care rehabilitation settings
Joseph‐Williams et al. (2014)27 UK	To systematically review patient‐reported barriers and facilitators to shared decision making, and develop a taxonomy of patient‐reported barriers.	Systematic review and thematic synthesis of 45 studies.	No	Primary, secondary, and community care
Lloyd et al. (2014)28 UK	To investigate physiotherapists' perceptions about their experiences of collaborative goal‐setting with patients in the sub‐acute stage after stroke.	Qualitative study (semi‐structured interviews).	9 physiotherapists	Hospital
Holliday et al. (2007)29 UK	To examine the impact of an increased participation goal‐setting protocol.	Qualitative study (comparison of usual participation with increased involvement in goal‐setting through a qualitative research design).	28 patients Mean age 49 Stroke, multiple sclerosis, subarchnoid hemorrhage, Guillian‐Barré Syndrome and spinal cord lesion.	Neurological rehabilitation unit
Bendz (2003)30 Sweden	To highlight ways in which people hit by a stroke and their health care professionals understand the implications of having a stroke.	Qualitative study (interviews and transcripts from the health care professionals' recording).	15 patients	At home
Holliday et al. (2007)31 UK	To explore how inpatients experienced two different types of goal‐setting, and identify the issues that underpin individuals' experiences of goal‐setting.	AB balanced block design controlled study.	201 patients	Neurological rehabilitation unit
Poulin et al. (2018)32 Canada	To understand how frailty impacts goal‐based care planning in regional geriatric services.	Qualitative study.	10 geriatric clinicians with diverse health professional backgrounds	Five different geriatric services

Table 2.

Studies on the nursing role included in the review

Authors	The objective of the study	Method	Participants	Setting
Tijsen et al. (2019)3 The Netherlands	To explore and describe the principles of Challenging Rehabilitation Environment.	Narrative review of 51 studies	No	Geriatric rehabilitation
Buijck et al. (2018)4 The Netherlands	Not applicablea	“Therapeutic Climate,” a chapter from “The Challenges of Nursing Stroke Management in Rehabilitation Centres.”	Not applicable	Stroke rehabilitation
Loft et al. (2017)15 Denmark	To explore nurses' and nurse assistants' beliefs and actions related to role and function in an inpatient stroke rehabilitation unit.	Qualitative study (participant observation and semistructured interviews).	Nurses (n = 8) and nurse assistants (n = 6).	Inpatient stroke rehabilitation unit
Loft et al. (2018)16 Denmark	To assess nursing staff members' self‐perceived outcomes related to their capability, opportunity and motivation to work with a rehabilitative approach after participating in the stroke rehabilitation 24/7 educational program.	Convergent mixed‐method design, consisting of a survey and semi‐structured interviews.	33 nurses filled in a questionnaire, 10 nurses were interviewed.	15‐bed acute stroke unit
Loft et al. (2017)33 Denmark	To describe patients' experiences with inpatient stroke rehabilitation and their perception of nurses' and nurse assistants' roles and functions during hospitalization.	Qualitative study (interviews).	10 stroke patients	Stroke rehabilitation unit in a university hospital
Elo et al. (2012)34 Finland	To describe gerontological rehabilitation nursing in an acute hospital setting from the nursing staff's points of view.	Cross‐sectional design was used.	Registered nurses (RNs) and practical nurses (PNs) (n = 367) from four different hospitals responded to the questionnaire.	Gerontological rehabilitation in an acute hospital setting.
Routasalo et al. (2004)35 Finland	To describe the development of a geriatric rehabilitation nursing model on the basis of the nursing and rehabilitation literature.	Literature review of 120 studies.	No	Geriatric rehabilitation
Suter‐Riederer, et al. (2018)36 Switzerland	To develop a common understanding of rehabilitation nursing care in Switzerland.	Delphi study	54 rehabilitation nursing stakeholders.	Neurorehabilitative settings
Kirkevold (2010)37 Norway	To propose an extended theoretical framework of the role of nursing in stroke recovery and rehabilitation.	The theoretical account is based on a review of recent research on stroke nursing and on patient experiences of living through the adjustment and rehabilitation process following a stroke.	No	Stroke rehabilitation
O'Connor (2000)38 UK	The aim of this study is to demonstrate that the perspective of a nurse's role in acute stroke rehabilitation should include a reference to the manner in which the functions (Kirkevold) are delivered.	Results from a recent study of nurses' and patients' perceptions of the nursing care in stroke units are used to demonstrate the mode of delivery of care that is required for the nurse's rehabilitative function to be fulfilled.	No	Stroke rehabilitation
Pryor et al. (2009)39 Australia	To explore nurses' understanding and expectations of rehabilitation and nurses' perceptions of patients' understanding and expectations of rehabilitation.	Qualitative study (interviews and observations).	53 nurses.	Five health care units in regional Australia providing rehabilitation and aged care/geriatric assessment services.
Sharp et al. (2016)40 Australia	To examine acute nursing care from the perspective of the person receiving the care, and then to interpret the meaning of this care in relation to the concept of person‐centered care (PCC).	Qualitative study (semi‐structured interviews).	10 former patients of an Australian regional health service.	A range of services, including mental health, oncology, and acute medical and surgical services.

^a Study book.

Thematic analysis was applied to identify common themes in the literature.^{41, 42} First, articles were thoroughly read at least twice (AV). Preliminary findings and ideas were coded. Codes were clustered and titled as themes (AV, RG). Subsequently a thematic map of the analysis was discussed and rearranged with the other researchers (CH, RG, PB, and EW). If present in the articles, quotes of patients were, after coding, added to the map, to support the debate.

3. RESULTS

3.1. Patients' needs concerning goal‐setting

The first objective of this analytic review was to provide an overview of the experiences of patients concerning goal‐setting. Table 1 presents a list of the 22 articles reviewed. From patients' experiences, certain needs can be distilled. Four themes emerged from the review: goals need to be personally meaningful, patients need to be prepared for the goal‐setting process, patients need information about their contribution to the collaborative process, and they need support in goal attainment through a customized approach.

3.2. Goals need to be personally meaningful

Patients and professionals differ in the way they look at recovery.^{7, 12, 20} Professionals approach it by setting measurable goals, often related to physical progress in a defined period of time, while patients think more in the long term, with less precise objectives like “back to how I was before the stroke” or “getting better.”^{5, 9, 20, 21, 22} While clients' motives for skill training are driven by the wish to participate in society, professionals focus on decreasing impairment; therefore, their goals are less meaningful to patients.²³ Patients will be motivated to do walking exercises when they apply it to their future hopes and dreams, for example being able to purchase a postcard from a museum for a relative, or in the example of grasping, being able to roll a cigarette.^{23, 24}

Rosewilliam et al.²⁵ state that patient‐centeredness in goal‐setting is uncommon, and that working with formal assessments and a hurried approach, focussed on short term goals achievable during the hospital stay, hinders exploration of the patient's preferences.

According to Van de Weyer et al.,²⁴ patients need a goal‐setting approach that allows more participation than usual to enable them to have a stronger voice in the rehabilitation process. Timmermans et al.²³ suggest that this starts with a client‐centered assessment. Thus patients' desires and aspirations will be better recognized.

3.3. Patients need to be prepared for the process

Patients percieve that they do not have enough information about goal‐setting and rehabilitation options to effectively participate in decisions about goals.^{12, 20, 25} When the patient is invited to goal‐setting discussions by various individuals within the multidisciplinary team, it can be challenging for the patient to untangle the situation they find themselves in, and to know to whom to address questions and with whom to talk about progress.¹⁰ Patients need an explanation regarding the process of goal‐setting to be prepared for this shared decision making process.^{7, 8, 12, 13, 26} Patients interviewed by Rose et al.⁸ experienced difficulty following communication about goal‐setting; they struggled to follow the conversation, causing them to forget the topics discussed.

3.4. Patients need information about the collaborative process

Generally, patients are inclined to accept the goals professionals set for them, because they see them as experts. They feel that through lack of medical knowledge they cannot play an equal part in the goal‐setting process.^{7, 20, 25, 26, 27, 28} Also, patients interviewed by Plant et al.⁷ pointed out that in the initial stage of their rehabilitation, the goals they would like to work on are quite obvious, and hence, do not need to be elaborately negotiated between professional and patient. A qualitative study by Van Seben et al.²¹ confirmed this, as during inpatient rehabilitation, patient goals are mainly related to regaining independence in self‐care activities. Patients do not recognize the complementary expertise about personal preferences and circumstances that they have.²⁷ When input is requested from patients on their personal wishes, experiences, and preferences, shared decision making is fostered.^{26, 27} This lack of clarity as to what is expected from them in the process of collaborative goal‐setting might result in a passive attitude, mistakenly understood by professionals as unmotivated behavior.^{8, 12} The way patients want to be involved in goal‐setting varies from individual to individual.¹⁴ This is partly because of personal preferences concerning involvement in goal‐setting, but also because of the uncertain nature of recovery.^{7, 20, 29}

3.5. Patients need to be supported in goal attainment

An important purpose of the collaboration on goals is to enhance patients' engagement in rehabilitation and to improve their task performance.^{7, 13} To achieve this, more focus needs to be put on goal achievement. Some patients undertake certain activities aimed at fulfilling their hopes and dreams, but these are hardly ever measurable or time‐bound.^{5, 20}

Davis⁵ interviewed fourteen COPD patients on their activity and exercise goals. The majority of the patients readily listed activity goals, but they gave no indication that they were appropriately exercising to accomplish these goals. Patients interviewed by Loft et al.³³ positively mention being given exercises for self‐training, but their motivation to work toward goals was hampered by the nursing staff's lack of involvement and support. Davis⁵ and Rosewilliam et al.¹² stated that clinicians overestimate patients' ability to work purposefully on activity goals by exercising without the help of clinicians. Action planning, agreeing on a course of action to achieve short‐term goals, addressing details such as what and how often, can structure and clarify the rehabilitation process for patients and their families. Turner‐Stokes et al. call it: “an educational process in which patients and their families are engaged (…) in taking responsibility for monitoring, achieving, and re‐setting goals along the journey of their recovery.” ^9(p210) Patients need a customized approach. Some patients flourish by small attainable goals, enabling their confidence to increase.^{7, 20} Others need large, ambitious goals to get motivated; there are even patients who like to keep their goals to themselves.²⁰ When it comes to working with time‐schedules, for some patients, they are useful, while others get nervous. Setting unrealistic goals needs to be avoided, and furthermore, patients and professionals need to be continually considering and reconsidering what can be worked on, what has gone well and what impeded progression.⁷ People's mental state should also be taken into account, as patients can, for example, suffer from fatigue or have fear of recurrence of their disease. Also, patients' emotional and social needs are not explicitly incorporated into, or may even be overlooked in goal‐setting processes.^{25, 30}

4. RESULTS: THE NURSING ROLE IN GOAL‐SETTING

The second objective of the analysis was to find out if patients' needs concerning goal‐setting could be met by the nursing profession. Table 2 presents a list of the 12 articles reviewed. Not all articles go into goal‐setting directly; some approach the subject from a less practical, more abstract level. However, goal orientation can be seen as the foundation of all nursing,^{34, 35, 36} which means, “the patient, family members, and professional staff together evaluate the patient's situation and set out goals for recovery, accept those goals, work toward them and evaluate results and aims.”³⁵

The theoretical framework of Kirkevold,³⁷ which described the nursing role in stroke rehabilitation, was referred to in many of the found articles.^{34, 35, 36, 38, 39} Kirkevold described the role in four functions: the interpretive, the consoling, the conserving and the integrative function. All functions elaborated in Kirkevold's framework,³⁷ except the conserving function, shine a light on the nursing role concerning goal‐setting. The conserving function is about meeting the patient's basic needs and preventing complications like pressure sores, obstipation, and nutritional deficits. Providing a safe environment, a pivotal aspect of nursing according to Suter‐Riederer et al.,³⁶ can also be seen as part of the conserving function. These activities are often not regarded as contributing to rehabilitation outcomes, however, they warrant an optimal starting position for rehabilitation therapies.³⁷

4.1. The interpretive function

Through the interpretive function, the nurse helps the patient understand what is the matter, what has to be done, and what the possibilities and impediments are, and makes patients aware of what rehabilitation requires from them, meanwhile encouraging patient and family not to lose hope for recovery.^{34, 37} The main goal of this function is increased understanding of the situation on the patient's part.³⁷ Rose et al.⁸ sum up several activities nurses can undertake: explain the word “goal,” explain what a goal‐setting meeting will entail and what the patients' role can be in the meeting, help the patient break down long‐term goals into smaller goals, help them set their agenda for exercises, summarize the content of discussions, and many more supporting and educative activities. Various articles emphasize the need to involve the family in this process.^{4, 33, 35} Families need: “knowledge, support, and an active role.”³⁵

4.2. The integrative function

The purpose of the integrative function is to help patients improve their daily functioning. Nurses integrate exercises in their daily work with the patient.³⁷ They do this by applying a facilitating and motivating attitude, working with their hands behind their back.^{4, 38} Buijck et al.⁴ and Tijsen et al.³ confirm the important role of nurses in creating opportunities to practice outside regular therapy sessions. Because nurses see older rehabilitation patients 24 h a day, they are in an important position to assess their possibilities of coping independently with essential tasks.³⁴ The integrative function entails applying the techniques of therapy in the care of the patient,^{15, 43} but also helps nurses transfer the techniques to other meaningful activities.³⁷ Subsequently, an effective principle of nursing intervention is the transformation of therapeutic outcomes into daily life. Nurses tailor their interventions toward the patients' preferences to enhance functionality and meaningfulness.³⁶

4.3. The consoling function

Through the consoling function, nurses provide emotional support, are present, and acknowledge the difficulties of the affected patients;³⁷ a change of health status can easily cause a sense of helplessness in older people.³⁵ Recognizing patient suffering, facilitating compassion, appreciating patients' individuality, and focussing on solutions are key principles of person‐centered care.⁴⁰

Emotional support is needed to instill hope and to encourage motivation.^{33, 34, 37} For the consoling function, a close and trusting relationship is needed.³⁷

4.4. Kirkevold's functions matched with patients' experiences

Table 3 matches Kirkevold's functions with patients' experiences.³⁷ The interpretive function is mainly educational, giving information concerning the path to recovery, thus meeting the need of patients to be prepared for the process of goal‐setting and achieving. Through the integrative function, the nurse translates skills from exercise sessions to everyday situations. Thus exercise sessions become meaningful activities and can, for example, be integrated into social activities.³⁸ Through the integrative function, they can also support goal attainment. Loft describes this as the hallmark of the nurse's function: “always being one step ahead, coordinating, planning, and maintaining an overview of the rehabilitation process.”¹⁵

Table 3.

Kirkevold's functions matched with patients' experiences

Patient's experiences	Nursing role using Kirkevold's functions as a framework
Goals should be meaningful “I am a Jehovah's witness and I always practiced door‐to‐door evangelism…. I hope it will get better soon, because having a curved back while standing at people's door is embarrassing.” 21 (p33) “How could they prepare me for coming home, they don't know about my home life … they certainly don't go over and above what they're meant to be doing, which is looking after you from a medical point of view.” 20 (p1023)	Integrative function: “These are complex situations where the focus is split between correct performance and the accomplishment of specific daily tasks and meaningful activities. Unless patients are able to see the relevance of the newly learned techniques for performing activities of importance, the specific rehabilitation goals identified by professionals lose their meaning and motivational power.” 37 (p29)
More info about process “The goal‐setting meeting yesterday was a lot better compared to in hospital. At least I knew what was going on and how they are going to help me.”8(p7) “What kind of goals?I am not that young you know…, no one's asked me. Apart from you … if I leave here I have to go and sort out myself, my way.” 25 (p514)	Interpretive function: “Making sense: Patients need help to interpret the situation by being provided with realistic and individually adjusted information to create a meaningful understanding of the situation.” 37 (p29)
More info about contribution to goal talk “The practitioner was seen as the expert and the participant accepted the direction they provided because it was ‘just assumed they knew their job'(Janet). ‘I was the novice,' commented Ian, ‘and they were the professionals.'” 20 (p1023)	–
More emphasis on achieving goals “I would have preferred them to break things down more… to help me understand how I could achieve going home and being independent. It is hard to understand what I need to do to achieve this.”8(p8) “I used to be quite scared about the future and didn't want to think about it much, I thought ‘What's the point?' There was too much to sort out. My goals seemed to break it all down so I could do it.” 29 (p392)	Integrative function: “A hallmark of the nurses' function and role was that they were always one step ahead; they were coordinating, planning and maintaining an overview of the rehabilitation process.” 15 (p4909) Console and motivate: “Consoling may also be needed to meet and endure the unpredictability and insecurity associated with the recovery process in order to maintain or instill hope and to encourage the motivation and hard work needed to regain as much functioning as possible.” 37 (p29)

Through the consoling function, nurses provide emotional support, known as soft rehabilitation.³⁴ The nurse supports the hard work that is needed to attain rehabilitation goals and recover as much as possible, and does this in a way customized to the patient's personality and preferences.

5. DISCUSSION

The first objective of this study was to provide an overview of the experiences and ensuing needs of patients concerning goal‐setting. Four aspects of the collaboration on goal‐setting and achieving can be improved: goals need to be personally meaningful; more guidance is needed for patients to optimally collaborate in the goal‐setting process; when patients are invited to be involved in goal‐setting discussions, it should be explained that input is requested not on medical aspects but on personal preferences and circumstances; finally, more emphasis should be put on the process of goal‐achieving.

The second objective of this study was to find out if the needs of patients concerning goal‐setting could be met by the nursing profession in geriatric rehabilitation. Kirkevold's functions of stroke nursing served as a framework for this inquiry.³⁷ Several functions meet the patients' needs adequately, so by strengthening the nurses' contribution to the multidisciplinary teamwork, these aspects of the collaboration on goal‐setting and achieving could be improved. Table 3, however, also uncovers two gaps. First, answering the need of patients to be informed about their contribution to the setting of goals is not described as part of the nursing role in any of the found articles. This might reveal that clinicians have a blind spot for this aspect of shared decision making. More knowledge is needed about that part of the nursing role, because functional goals can only be translated into meaningful goals if patients participate in the goal talk, adding their personal preferences. Second, although the integrative function concerns planning and coordinating the rehabilitation process, none of the authors touch upon the question of whether the nurse does this solely to structure his or her own work or also for the benefit of the patient's understanding of the process. We recommend further research on this topic. Additionally, the literature reveals certain barriers and facilitators for nurses to optimally play their role in setting and achieving goals with patients in general, and specifically in the above‐mentioned two gaps: interprofessional collaboration, clear work procedures and materials, continuity, time and trust, and the physical environment all make an impact.

The multiplicity of disciplines, a strength of interprofessional collaboration in the geriatric rehabilitation practice, can become a weakness, as the multiple messages may cloud the patients' understanding of the process, particularly considering the cognitive frailty of the patients.⁹ Patients are not aware that rehabilitation is a 24/7 process. They distinguish rehabilitation care, provided by, for example, physiotherapists, from nursing care.^{11, 15, 39} The use of overarching patient‐centered goals is an answer to this barrier; it unites team members around a shared purpose rather than pursuing separate discipline‐specific activities.^{28, 43, 44, 45} This shared planning and delivery supports nurses in their interpretive and integrative function, and additionally, it facilitates interprofessional learning.^{45, 46}

Clear working methods when it comes to goal‐setting are also mentioned as a prerequisite for nurses to play their role,¹¹ clear, simple elements that can be embedded in the daily routine of all staff members, which will improve the interpretive and integrating role of the nurse. Subsequently, these will help patients play an active role in their own rehabilitation, both in setting goals and in customizing them to their personal needs and working toward achieving them.^{31, 32, 46}

Goal‐setting has proven to be a process driven by professionals aimed at preparing patients for discharge. Several studies^{7, 8, 12, 26} recommend working with supporting material: pictures of goals, lists of examples of goals, exercise plans divided into stepping stones, worksheets, explicit methods of patient involvement, the care plan as a shared document with which to follow progress, exercise books. According to Plant et al.,⁷ “participants felt these tools help to clarify expectations, guide patient‐led therapy, enable progress to be monitored and facilitate family involvement.”^(p.926) Which criteria these methods and materials should meet to support patients' needs and to fit into the nursing routine is an important area for further study.

Another condition nurses mention is lack of continuity in care, caused for example by working in shifts and by lack of consistent patient assignment to nursing team members.^{7, 13} Related to continuity, time is also mentioned as a prerequisite for optimal collaboration on goals between clinicians and patients.^{7, 12, 25, 26} Time and continuity are crucial prerequisites for building a relationship and thus for gaining knowledge about patients' preferences, concerns, goals and progress to optimally guide them through their process of recovery.^{15, 36} Finally, the physical environment in the ward is described as a facilitator.^{3, 15} Loft et al.¹⁵ illustrated this with a ward in which there were only two bathrooms: “nurses and nurse assistants choose to wash and dress the patient in their room because they did not have time for the bathroom to become available, and the patient consequently missed the opportunity to practice….” (p.4911)

5.1. Strengths and limitations

This study contributes to the clarification and strengthening of the nursing role concerning goal‐setting in the multidisciplinary team—an important subject, given the fact that the population is aging and more elderly will need support to return to their homes in the best possible condition. Gaps in nurses' role were revealed, as well as facilitators and barriers to filling in these gaps adequately. The limitation of a narrative review is that it lacks an explicit intent to maximize scope.⁴⁷ The conclusions we have drawn could be biased from the fact that, inadvertently, significant sections of the literature have been missed, or from the fact that the validity of statements have not been questioned.⁴⁷ Another risk on bias is that the articles were selected by one researcher. Nonetheless, the literature reviewed unambiguously emphasized that patients need to be guided in or educated about the process of goal‐setting. A considerable amount of the literature focusses on patients who have experienced a stroke, a patient group with exceptionally challenging conditions, such as cognitive and communicative problems, the sudden onset of the disease and the trauma these aspects of the disease cause. This might influence the outcome of this narrative review. On the other hand, 16% of the population in geriatric rehabilitation are stroke patients, and like stroke patients, geriatric patients are frail and often cope with cognitive problems.⁴⁸

6. CONCLUSION

Because setting goals is primarily an activity initiated by professionals and not a natural way of working at recovery for patients, patients need an explanation about the process and their role in it, the latter to ensure that set goals are meaningful for patients. Both the literature about patients' needs as regards goal‐setting and the literature about the nursing role in rehabilitation make clear that the way we work in rehabilitation can gain in clarity. Talking about and being occupied with (achieving) goals should determine the daily routine in geriatric rehabilitation. For nurses to perform these functions, working on shared patient‐centered goals in the multidisciplinary team is a central issue. Second, clear work procedures and material should support the collaborative process of “goal‐talk” and increase the transparency of the rehabilitation process and its possibilities. Third, continuity of care is important to build a relationship of trust within which patients are invited to share their personal preferences. Further, the physical environment needs to be optimal for integrating exercises into daily care.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.

Vaalburg AM, Wattel E, Boersma P, Hertogh C, Gobbens R. Goal‐setting in geriatric rehabilitation: can the nursing profession meet patients' needs? A narrative review. Nurs Forum. 2021;56:648–659. 10.1111/nuf.12562