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What is This?
Editorial
Goal setting in rehabilitation: an overview Thus it should be no surprise that the identifi-
of what, why and how cation and setting of goals with patients in reha-
bilitation is a core component of the process,
much more so than in most other parts of health
Setting goals with the patients and monitoring care.
their achievement is a core practice within much This issue of Clinical Rehabilitation includes
rehabilitation, but the evidence base behind seven papers concerned with aspects of the goal-
this practice is patchy. This issue of Clinical setting process. This Editorial sets these papers in
Rehabilitation has seven articles concerned with
the context of the whole process of goal setting.
various aspects of goal setting, and this Editorial
It first considers what goals are, the reasons for
sets them in context. It considers the theoretical
setting goals, and the theories that underlie goal
basis underlying goal setting, especially in rehabi-
setting. Then it moves on to some practical issues
litation. It argues that a goal is the intended out-
around setting particular goals and issues concern-
come of a specific set of interventions. It suggests
ing measurement of goal achievement. Finally it
setting goals has benefits beyond simply motivat-
draws attention to the resource implications of
ing the patient and team; it may coordinate activ-
goal setting and how this might influence clinical
ities and ensure that all necessary goals are
practice.
identified. It reviews whether goals should be
SMART (and what SMART means), and empha-
sizes that there may be a hierarchy of goals on two
axes (time, abstractness). It reviews the benefits Goals and goal setting
and problems of goal attainment scaling and,
finally, considers the ethical problems associated
with goal setting. It concludes that goals should The Oxford English Dictionary defines a goal
not necessarily be completely SMART, and that as ‘The object to which effort or ambition is direc-
goal attainment scaling may only be useful as a ted; the destination of a (more or less laborious)
measure in research. It emphasizes the need for journey. spec. in Psychol. An end or result towards
much more research into the cost-effectiveness of which behaviour is consciously or unconsciously
this activity. directed.’ It is important to note there are two
components to this definition: an end state and
an effort to reach that state.
Thus in the context of rehabilitation, goals have
Introduction two characteristics. First a goal is an intended
future state; this will usually involve a change
Most human behaviour is goal-directed. In other from the current situation although, in some
words, people generally act for a reason, however circumstances, maintenance of a current state in
nebulous or unconsidered that reason is. the face of expected deterioration might be a
Rehabilitation is ultimately concerned with changing goal. Second, and of equal importance, a goal
behaviours. One objective of rehabilitation is to refers to the intended consequence of actions
reduce ‘activity limitation’ (in the World Health undertaken by the rehabilitation team. A goal is
Organization’s (WHO) International Classification not nor should be a simple prediction of what will
of Functioning, Disability and Health (ICF) termi- happen; it should be the intended result of some
nology1); the goal is to increase a patient’s beha- intervention(s).
vioural repertoire as much as possible, within any Goal setting, sometimes referred to as goal plan-
constraints imposed by disease and impairments. ning, is the formal process whereby a rehabilitation
ß SAGE Publication 2009
Los Angeles, London, New Delhi and Singapore 10.1177/0269215509103551
professional or team together with the patient achieving the overall goal can be started (if it
and/or their family negotiate goals. Although pro- exists).
fessionals and teams will always have some reason Lastly it has been suggested that the setting of
for their actions, the goals are often unstated and goals may help the patient in other ways. It may
unconsidered in the particular situation. In rehabi- reduce anxiety4 and it might increase insight into
litation the goal-setting process ensures explicit and acceptance of limited recovery.5
identification of the reasons for all activity.
ensure that important actions are not over- It is also very important to link goals one to
looked; and another so that the patient can see the connection
allow monitoring of change to abort ineffective between their own longer term aspirations and the
activities quickly. more immediate rehabilitation goals being sug-
gested. Further, if the process starts from a small
When only one person is involved with a patient number of high-level goals it is more likely to iden-
and the intervention is relatively brief and simple, tify most necessary actions and it may also encou-
then a formal goal-setting process is less likely to rage interdisciplinary working with shared goals.9
be needed. Nevertheless the considerations and Finally there is the process of documenting or
processes described below should be used, albeit recording the goals set, so that progress can be
in an abbreviated way. evaluated and so that all team members (including
The first step is to establish what goals are the patient) know what is expected of them.
important to the patient, because goals are only
effective if they are considered desirable by the
subject. Establishing the patient’s goals is not
trivial and it is rarely wise to make assumptions Setting a particular goal – being SMART
about the wishes and expectations of individual
patients in any situation, however obvious they Most of the research into goal setting has focused
may appear. The process should also consider on the nature of a goal, and how manipulating
the wishes and expectations of other important aspects of a particular goal may alter its effects.
parties such as the family, work colleagues, those This has led to guidance on setting the ideal goal,
who are funding rehabilitation, and even the reha- and the acronym usually associated with this is
bilitation team itself. SMART. It is uncertain when this acronym was
At the same time the process needs to establish first developed10 but the earliest known publication
what changes are at least possible and what is in 1981 when two articles in one journal men-
changes are not possible, and what would be tioned the acronym, one in the title.11 More recently
needed to achieve each goal and how likely the the acronym SMARTER has also been used.
change is. While this may be easy in some circum- There is considerable variation, however, in the
stances, it is often difficult, especially in complex actual words associated with each letter in both of
situations where a whole team is involved. these acronyms. Table 1 shows at least some of
These preparatory stages are followed by a pro- the words; these were derived from various web-
cess of sharing information and negotiating a set sites10,12–14 and other papers. Although at least
of goals that between them acknowledge most or two of the words used are difficult to interpret
all of the wishes of the patient and resolve as many (‘magical’, ‘magnetic’), it is likely that the under-
problems as possible. This is not to say that all of lying concepts encompassed within the many
the patient’s wishes are set as goals. It is to say that words used are important when setting goals.
some account is taken of their wishes, and some Practical guidance on how to set SMART goals
response made. is given in one paper in this issue.15
In the process of goal setting it is important to Although being SMART is often said to be
recognize that goals are hierarchical in at least two vital, it is worth quoting some sentences from
ways. The first axis relates to time: there are long- one of the earliest papers11 that referred to setting
term goals (usually few in number), medium-term goals in management. Doran wrote:
and short-term goals. The second axis relates to
the conceptual level. One example is the hierarchy In certain situations it is not realistic to attempt
of needs given by Maslow,8 who identified needs quantification particularly in staff middle-man-
as being physiological, safety, love/belonging, agement positions. Practicing managers and
esteem and self-actualization. An alternative corporations can lose the benefit of a more
example is the WHO ICF model,1 where goals abstract objective in order to obtain quantifi-
might concern social participation, activities, cation. It is the combination of the objective
impairments or well-being. and its action plan that is really important
Table 1 Some of the words associated with each letter of the acronyms SMART and SMARTER in the
context of goal setting