Abstract
Background
Goal setting is done in collaboration with the patient, but patient identified (PID) goals are not always addressed. The purpose of this study was to determine reasons PID goals are not set in low vision rehabilitation and for which tasks.
Methods
Occupational therapists completed an individualized survey to determine from 15 probable reasons why they did not set a PID for specific tasks.
Results and Conclusion
PID goals were not set for 3 ADL, 13 IADL, 4 Social Participation, and 10 Leisure tasks. Further research is needed to understand how prioritization of PID goals differ between therapist and patient.
Keywords: Patient identified goals, goal setting, occupational therapists, survey research, low vision
Background
Goal setting is important in rehabilitation and is dependent upon a skilled therapist.1 Goals are to be set in collaboration with patients who are motivated to work on goals they want to achieve. However, goal setting involves more factors than patient aspirations such as a patient’s rehabilitation potential, safety issues, cognitive abilities, and third-party payer polices. Goals must also be feasible, achievable and a priority. In addition, therapists must consider their practice domain, skill level, ethical standards, and licensure laws.2
Different goal setting strategies have been utilized to improve patient goal attainment. McPherson et al. compared Goal Management Training and Identity Oriented Goal training and determined that many of the participants in both groups had improved goal attainment.3 They found the Identity Oriented Goal Training helpful in achieving collaboration between therapist and patient in goal setting and Goal Management Training aided in preventing errors when patients attempted goals. More recently, Dekker et al. developed a tool to aid in setting meaningful goals. To be meaningful, goals must be of importance to the patient.4 Dekker et al. postulated that setting meaningful goals requires exploration of a patient’s “fundamental beliefs, goals, and attitudes” (p. 7).4 They used a three-step process of first exploring global meaning, second setting of the meaningful overall rehabilitation goal, and the third step of setting and adjusting of specific rehabilitation goals. Goal attainment scaling is commonly used in rehabilitation goal setting.5–8 Each patient goal is measured with a 5-point scale with a range of −2 to +2. A baseline measure is determined and an expected level following rehabilitation. Using this approach, the therapist can weigh the importance of goal to the patient, but this is optional.8
Factors such as patient population and setting in which intervention occurs can affect how goals are prioritized and the level of importance they have for a patient. Researchers have examined goal setting for patients with specific diagnoses such as stroke 2,9,10 and/or traumatic brain injury.3,11 Cognitive effects, communication difficulties, and fatigue and mood disorders associated with these diagnoses may cause different issues in goal setting.11 Another focus of researchers has been goal setting in different types of settings including acute 9,12, subacute 13,14, and inpatient rehabilitation.9,12,15 Patient needs vary in different levels of care and the time within a setting affects the length of patient goals.
Studies have shown that perceptions of the goal setting process and outcomes differ between therapists and patients.11,12,16,17 Despite striving for a collaborative nature of goal setting between the therapist and patient, at some point in establishing or enacting the plan of care (POC) therapist/patient perspectives can diverge. Common points of divergence include patients do not perceive the purpose of clinic intervention as related to their goals3 while therapists perceive patient’s goals as vague and broad.9,12 Therapists set many goals for body structure or body function17 and basic ADLs11,18; and do not focus enough on patient hobbies or interests.3,9
Inherently, the relationship between the clinician and the patient is unequal.15 When a variance occurs between the patient and the clinician in goal setting, researchers have found they are handled differently. Parry found therapists used negotiation and amending of proposed goals12, while Barnard et al. determined the treating team led goal modification to ensure goals were achievable.15 Levak et al. concluded that a ‘patient-centered’ approach to goal setting may not be possible due to third-party payer policies.2
There are a limited number of studies on goal setting in rehabilitation and none located on setting goals in low vision rehabilitation. Further, few studies were found that address the different types of tasks or areas of occupations for which patient identified goals (PID) are not being set. A study is needed on reasons occupational therapists choose not to include a PID goal in a patient POC. The purpose of this study is to explore the determinates of goal setting of PID goals by occupational therapists for patients with low vision and the areas of occupation most likely to have PID goals set.
There are two research questions in this study. (1) What reasons affect whether an occupational therapist includes a patient identified goal in the patient’s plan of care? (2) In which areas of occupation are patient identified goals most likely to be included in a patient’s plan of care?
Methods
Research Design and Instrument
A survey research design was used for this study. An initial survey was developed by the investigator with 11 most likely reasons affecting occupational therapists’ decision not to include a patient identified (PID) goal in POC. The initial survey was piloted with an occupational therapist who recommended that an additional four reasons be added to the survey. The survey used in this study includes 15 most likely reasons (See Table 1) affecting occupational therapists’ decision not to include a PID goal in POC. Patient identified goals were determined using the Activity Inventory (AI) which contains 50 goals.19 If a patient rated an activity on the AI as important and moderately difficult to complete, it was considered a PID goal.
Table 1.
Survey of Reasons Not to Set a Patient Identified Goal on the Activity Inventory
| ___Goal judged not to be a priority |
| ___Many other goals that the patient wanted to work on |
| ___Goal could not be attainable in a reasonable time |
| ___Patient has caregiver to perform task and patient choose not to address |
| ___ Cognitive deficits would interfere with goal attainment |
| ___Patient goals are not attainable or are unrealistic |
| ___Family requests that goal not be addressed |
| ___Financial barriers to purchasing necessary equipment to achieve goal |
| ___I did not feel competent to address that goal |
| ___Patient referred to another professional to address goal |
| ___Wording of goal very general and a more precise goal was established |
| ___Goal attainment does not meet medical necessary guidelines |
| ___Decline in medical status |
| ___Safety concerns of patient attempting goal |
| ___Patient at goal level |
Using data from a larger study, therapists’ goals for their patients with low vision were collected and an individualized survey was constructed for each therapist. The individualized therapist surveys included all PID activities for which they had not set a goal followed with a list of 15 probably reasons they did not set a goal. The surveys included only PID goals on the AI for which the individual occupational therapist did not include a goal in the patient’s POC.
Participants
Participant inclusion criteria were occupational therapists who were treating patients with low vision and who were known to the researcher due to their participation in a larger study. Exclusion criteria were occupational therapists not using the AI outcomes, and who were not participants in the larger study.
Study Procedures
Potential participants were sent a cover letter by email asking for their participation in this study. If they agreed to participate, they emailed the investigator back thereby providing informed consent to be in the study as approved by the Institutional Review Board of the university for which the investigator was affiliated at that time. After consent was obtained, occupational therapists completed their individualized survey. The therapist returned an electronic copy of their individualized survey to the investigator via email indicating the reasons out of 15 probable reasons that they did not make a goal for a PID goal.
Data Collection and Analysis
Data were obtained from the individualized therapists’ surveys and were tabulated for each therapist, and then across therapists. A matrix was developed to include all PID goals not included by the occupational therapists in patients’ POC (See Table 2), and the reasons therapists gave for not setting a PID goal. Only reasons for which a majority of the therapists excluded a PID goal from patient POC were listed on the matrix. Totals of PID goals not set in the patient POC were calculated. Goals were then grouped by the investigator into areas of occupations of basic activities of daily living (ADLs), instrumental activities of daily living (IADLs), Leisure, and Social Participation, and were then ranked.
Table 2.
Reasons (chosen by 3 or more therapists) for Not Setting a Patient Identified Goal in ADLs, IADLs, Social Participation, and Leisure
| Occupation category and activity | Activity Inventory goal | Reason goal not set | Number of therapists whose chose reason not to set goal | # of therapists |
|---|---|---|---|---|
| Goal$(1)=“use the restroom in a public place” | ||||
| ADLs | 1 | Goal judged not to be a priority | 4 | 4 |
| ADLs | 1 | Many other goals that the patient wanted to work on | 4 | 4 |
| ADLs | 1 | Patient goals are not attainable or are unrealistic | 3 | 3 |
| ADLs | 1 | Safety concerns of patient attempting goal | 3 | 3 |
| ADLs | 1 | Patient at goal level | 3 | 3 |
| Goal$(3)=“choose your clothes and dress yourself” | ||||
| ADLs | 3 | Patient has caregiver to perform task and patient choose not to address | 4 | 4 |
| ADLs | 3 | Cognitive deficits would interfere with goal attainment | 3 | 3 |
| ADLs | 3 | Patient at goal level | 3 | 3 |
| Goal$(5)=“eat your meals” | ||||
| ADLs | 5 | Patient at goal level | 3 | 3 |
| Goal$(4)=“take care of your health” | ||||
| IADLs | 4 | Cognitive deficits would interfere with goal attainment | 3 | 3 |
| IADLs | 4 | Safety concerns of patient attempting goal | 3 | 3 |
| Goal$(7)=“perform household tasks such as cleaning, laundry, or setting a thermostat” | ||||
| IADLs | 7 | Patient has caregiver to perform task and patient choose not to address | 4 | 4 |
| IADLs | 7 | Safety concerns of patient attempting goal | 3 | 3 |
| Goal$(9)=“read mail and write letters” | ||||
| IADLs | 9 | Patient has caregiver to perform task and patient choose not to address | 4 | 4 |
| IADLs | 9 | Cognitive deficits would interfere with goal attainment | 4 | 4 |
| Goal$(11)=“read the time and follow a schedule” | ||||
| IADLs | 11 | Cognitive deficits would interfere with goal attainment | 3 | 3 |
| Goal$(12)=“pay bills, balance accounts, or manage personal or household finances” | ||||
| IADLs | 12 | Patient goals are not attainable or are unrealistic | 3 | 3 |
| Goal$(13)=“go shopping for food, clothes or other necessities” | ||||
| IADLs | 13 | Goal judged not to be a priority | 3 | 3 |
| IADLs | 13 | Goal could not be attainable in a reasonable time | 3 | 3 |
| IADLs | 13 | Patient has caregiver to perform task and patient choose not to address | 4 | 4 |
| IADLs | 13 | Safety concerns of patient attempting goal | 3 | 3 |
| Goal$(14)=“care for young children” | ||||
| IADLs | 14 | Goal judged not to be a priority | 3 | 3 |
| IADLs | 14 | Safety concerns of patient attempting goal | 3 | 3 |
| Goal$(15)=“drive” | ||||
| IADLs | 15 | Patient goals are not attainable or are unrealistic | 5 | 5 |
| IADLs | 15 | Patient referred to another professional to address goal | 3 | 3 |
| IADLs | 15 | Safety concerns of patient attempting goal | 4 | 4 |
| Goal$(16)=“provide home care for an adult” | ||||
| IADLs | 16 | Safety concerns of patient attempting goal | 3 | 3 |
| Goal$(17)=“provide care for a pet” | ||||
| IADLs | 17 | Many other goals that the patient wanted to work on | 3 | 3 |
| IADLs | 17 | Patient has caregiver to perform task and patient choose not to address | 3 | 3 |
| IADLs | 17 | Patient at goal level | 3 | 3 |
| Goal$(21)=“cook or bake for social functions (for example, Thanksgiving or other holidays)” | ||||
| IADLs | 21 | Goal judged not to be a priority | 3 | 3 |
| IADLs | 21 | Many other goals that the patient wanted to work on | 4 | 4 |
| IADLs | 21 | Goal could not be attainable in a reasonable time | 3 | 3 |
| IADLs | 21 | Cognitive deficits would interfere with goal attainment | 3 | 3 |
| IADLs | 21 | Patient goals are not attainable or are unrealistic | 4 | 4 |
| IADLs | 21 | Safety concerns of patient attempting goal | 4 | 4 |
| IADLs | 24 | Many other goals that the patient wanted to work on | 3 | 3 |
| Goal$(47)=“use a computer” | ||||
| IADLs | 47 | Cognitive deficits would interfere with goal attainment | 4 | 4 |
| IADLs | 47 | Patient goals are not attainable or are unrealistic | 3 | 3 |
| IADLs | 47 | Financial barriers to purchasing necessary equipment to achieve goal | 3 | 3 |
| Goal$(8)=“recognize people, see expressions, and make eye contact during personal communications” | ||||
| Social Participation | 8 | Patient goals are not attainable or are unrealistic | 5 | 5 |
| Social Participation | 8 | Patient at goal level | 3 | 3 |
| Goal$(19)=“attend parties or other functions” | ||||
| Social Participation | 19 | Goal judged not to be a priority | 3 | 3 |
| Social Participation | 19 | Many other goals that the patient wanted to work on | 4 | 4 |
| Social Participation | 19 | Goal could not be attainable in a reasonable time | 3 | 3 |
| Social Participation | 19 | Cognitive deficits would interfere with goal attainment | 3 | 3 |
| Social Participation | 19 | Patient goals are not attainable or are unrealistic | 3 | 3 |
| Social Participation | 19 | Patient at goal level | 3 | 3 |
| Goal$(22)=“dine out” | ||||
| Social Participation | 22 | Patient goals are not attainable or are unrealistic | 3 | 3 |
| Social Participation | 22 | Patient at goal level | 3 | 3 |
| Goal$(26)=“sing in a choir or play an instrument publicly, perform in plays, speak publicly or perform before a group” | ||||
| Social Participation | 26 | Many other goals that the patient wanted to work on | 3 | 3 |
| Social Participation | 26 | Patient goals are not attainable or are unrealistic | 3 | 3 |
| Goal$(23)=“attend plays, concerts, movies, sporting events, etc” | ||||
| Leisure | 23 | Many other goals that the patient wanted to work on | 4 | 4 |
| Leisure | 23 | Goal could not be attainable in a reasonable time | 3 | 3 |
| Leisure | 23 | Cognitive deficits would interfere with goal attainment | 3 | 3 |
| Leisure | 23 | Patient goals are not attainable or are unrealistic | 3 | 3 |
| Leisure | 23 | Patient at goal level | 3 | 3 |
| Goal$(25)=“play cards, board games, Bingo, or other games” | ||||
| Leisure | 25 | Goal judged not to be a priority | 3 | 3 |
| Leisure | 25 | Many other goals that the patient wanted to work on | 5 | 5 |
| Leisure | 25 | Cognitive deficits would interfere with goal attainment | 3 | 3 |
| Leisure | 25 | Patient at goal level | 3 | 3 |
| Goal$(28)=“dance socially” | Goal$(28)=“dance socially” | |||
| Leisure | 28 | Many other goals that the patient wanted to work on | 3 | 3 |
| Goal$(35)=“paint or draw” | ||||
| Leisure | 35 | Many other goals that the patient wanted to work on | 4 | 4 |
| Goal$(36)=“cook or bake for recreation” | ||||
| Leisure | 36 | Cognitive deficits would interfere with goal attainment | 3 | 3 |
| Leisure | 36 | Safety concerns of patient attempting goal | 4 | 3 |
| Goal$(39)=“play a musical instrument” | ||||
| Leisure | 39 | Goal judged not to be a priority | 5 | 4 |
| Leisure | 39 | Many other goals that the patient wanted to work on | 4 | 4 |
| Leisure | 39 | Goal could not be attainable in a reasonable time | 3 | 3 |
| Leisure | 39 | Patient goals are not attainable or are unrealistic | 4 | 4 |
| Goal$(40)=“travel” | ||||
| Leisure | 40 | Goal judged not to be a priority | 4 | 4 |
| Leisure | 40 | Many other goals that the patient wanted to work on | 4 | 4 |
| Leisure | 40 | Goal could not be attainable in a reasonable time | 3 | 3 |
| Leisure | 40 | Patient goals are not attainable or are unrealistic | 4 | 4 |
| Leisure | 40 | Safety concerns of patient attempting goal | 4 | 4 |
| Goal$(43)=“perform outdoor recreational activities; e.g., boating, hiking, camping, etc.” | ||||
| Leisure | 43 | Safety concerns of patient attempting goal | 3 | 3 |
| Goal$(44)=“garden for pleasure or work in the yard” | ||||
| Leisure | 44 | Safety concerns of patient attempting goal | 3 | 3 |
| Goal$(45)=“play sports; such as, golf, bowling, tennis, etc.” | ||||
| Leisure | 45 | Many other goals that the patient wanted to work on | 4 | 4 |
| Leisure | 45 | Goal could not be attainable in a reasonable time | 3 | 3 |
| Leisure | 45 | Patient goals are not attainable or are unrealistic | 3 | 3 |
| Leisure | 45 | Safety concerns of patient attempting goal | 3 | 3 |
Results
Participants
Five occupational therapists who met the inclusion criteria completed their individualized survey on their patients among the 91 community dwelling patients in the study. Four of the occupational therapists practiced in home health and a fifth saw patients in an outpatient vision clinic.
Patient Identified Goals Not Set
The reasons provided for not setting goals varied for the different tasks in the areas of occupation (See Table 2). The most common reason to not include PID goals in the patient’s POC for IADLs tasks was ‘goals are not attainable or are unrealistic.’ Leisure task goals were not set due to ‘many other goals the patient wanted to work on.’ Three tied reasons resulted in ADLs tasks not being set including: ‘many other goals that the patient wanted to work on’; ‘goal judged not to be a priority’; and ‘patient has caregiver to perform task and patient choose not to address.’ The reason therapists gave for not setting a PID goal for Social Participation tasks was ‘many other goals that the patient wanted to work on.’
Reasons for Goals Not Set
Patient identified goals were not set by therapists for 3 of the ADL tasks, 12 IADL tasks, 4 Social Participation tasks, and 10 Leisure tasks (See Table 2). The occupation category most often not to have PID goals set was IADLs followed by Leisure, Social Participation, and ADLs.
Discussion
This study addressed two research questions. For question (1) the most common reason given to not set PID goals was ‘many other goals that the patient wanted to work on’ except for IADL tasks. The most common reason to not set a PID goal for an IADL task was the goal was ‘not attainable or are unrealistic.’ For question (2) ADL was the area of occupation with the most PID goals set followed by Social Participation, Leisure, and IADL.
The relevance of setting meaningful goals important to the patient is well supported by many researchers.4,19,20 Setting meaningful goals was addressed in this study by selecting only goals from AI which patients found important as well as moderately difficult which aligns with Wade’s template for goal setting.20 Wade lists the first step in the goal setting process as establishing what is important for the patient.20 We accomplished this in our study by having the patient first rate the importance of a goal followed by how difficult they rated the goal would be to achieve when completing the AI.
Other researchers have ascertained similar reasons as in this study that affect setting of PID goals. Therapists in our study chose not to set a PID goal because it is ‘not attainable or are unrealistic.’ This compares to Wade declaring it is important to determine what changes are possible or impossible.20 Barnard et al. expressed the same sentiment by reporting that therapists tended to write goals that they considered achievable.15 The most commonly selected reason by therapists in this study to not set a PID goal was ‘many other goals that the patient wanted to work on.’ This reason may be interpreted as not enough time to achieve these goals and can be attributed to the healthcare system restrictions).10,11,13
Our findings were comparative to those of researchers who uncovered discrepancies in matching therapists’ goals with PID goals. In a study by Saito et al., therapists set 239 goals to patients’ 161.17 Despite setting more goals than their patients, only 21% of therapists’ goals matched those of their patients.17 In a comparison of therapist and patient perceptions of goal setting, McAndrew et al. found patient participants were least positive of the inclusion of their interests or hobbies in the goal-setting process.16 Although, people with low vision are generally older and older people spend more time in leisure activities, PID Leisure goals were not frequently set in this study. We also found ADL tasks had the least amount of PID goals excluded as found by other researchers.11,18
There were several limitations in the study. Although the study included data from 91 patients, one of the occupational therapists collected data on 45 of them in the home resulting in that therapist contributing almost half of the data. Nor were the number of tasks for each area of occupation equal in number. Requirements of individual setting or third-party payers may have influenced whether a therapist set a PID goal. Therapists did not rate why they did not set PID goals of a specific patient but in general why they would be most likely not to set a PID goal for a given task. Therefore, it cannot be known how patient or context factors may have influenced the clinical reasoning of the occupational therapists during goal setting in this study.
Future research should include differences in goal setting in settings not dependent upon third-party payers such as the Veterans Administration in the US and low vision rehabilitation settings in other countries that have public health services. Studies on how a patient’s gender, co-morbidities, and support system affect whether a PID goal is set would yield valuable information. Goal setting for additional diagnoses and other age groups should also be studied by researchers. Lastly, future research is needed to determine how prioritization of PID goals differ between therapist and patient.
Conclusion
Occupational therapists in low vision rehabilitation in part prioritize goal setting by limiting the number of goals set in the patient’s POC.
Acknowledgement
I thank Dr. Robert W. Massof for his guidance in this research study
Funding
Funding for this study was provided by the National Eye Institute of the National Institutes of Health Grant entitled “Comparative studies of low vision rehabilitation outcome measures” (4RO1EY022322–05)
Footnotes
Conflicts of interests
The author has no conflicts of interests.
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