COVER STORY: HOW I...

HOW I SET GOALS

WHERE YOU GONNA BE IN TEN YEARS TIME AND WILL YOU BE HAPPY WITH THE WAY YOUVE BEEN LIVING YOUR LIFE?... COS WHEN YOURE LOOKING BACK TO NOW ON THE YEARS GONE BY WILL THERE BE SOMETHING THAT YOU SAY THAT YOU SHOULD HAVE DONE RIGHT IN YOUR LIFE? IN THE SONG TEN YEARS TIME GABRIELLE ASKS, DO YOU HAVE A VISION? DO YOU HAVE A GOAL? OUR THREE CONTRIBUTORS REFLECT ON THE PROCESS, ADVANTAGES AND CHALLENGES OF GOAL SETTING WITH CLIENTS.

HOW WOULD YOU

GO ABOUT IT?
GOAL SETTING IS MEANT TO BE INTEGRAL TO REHABILITATION BUT IT DOESNT ALWAYS HAPPEN. SARAH EASTON FINDS OUT WHAT WOULD ENCOURAGE US TO DO MORE OF IT.
Do you have a five year plan? Do you have an idea of what you wish to achieve this week? Do you have a to do list? Will you achieve all you want to, even if all the appropriate factors are in place and you have enough resources? Or might tasks get left undone for no real reason that you can explain? We all have goals in our lives, targets to be achieved, usually within a time frame. Although we are not always successful at completing them, simply having something to aim for seems to be important. That is in our private lives, but what does this mean for our work with adults with acquired communication disorders? Communicating Quality 2 (RCSLT, 1996) and Clinical Guidelines by Consensus for Speech & Language Therapists (RCSLT, 1998) both stress the importance of discussing goals - and their achievement or otherwise - with patients. Communicating Quality 2 states (p. 22) that, throughout speech and language therapy involvement, Achievable goals will have been identified and agreed between the speech and language therapist and client and carer. These will include expected outcomes and time-scales. The importance of full documentation for all appropriate professionals to access is also highlighted. This is central to patient care and all outcomes. However, Johnson & Faulkner stated at the 1995 RCSLT conference that Goal setting is often very imprecise, partly because of our lack of confidence in making predictions This lack of confidence was evident in Portsmouth five years later, with staff requesting training and support on goal setting. Hence we began by asking the question: Are we setting goals with adults with acquired communication disorders? Our department established a small descriptive case study of process with the support of Portsmouth Institute of Medicine, Health and Social Care, Portsmouth University, to learn what was happening locally. This involved all 21 speech and language therapists working with adults, over a three month period, within a Primary Care Trust covering city and rural environments, and a comprehensive range of sites and methods of service delivery. The population covered is almost 600,000 (Census, 2001). Questionnaire evidence (n=21) was supported by four semi-structured interviews. A full range of data was gathered relating to the process, factors influencing goal setting and how the patient, carers and other professionals are involved, plus examples of goals set within current cases (n=105). We used cross case analysis to interrogate the data. No patient information was accessed as this study did not set out to address the appropriateness or SMARTness of the goals set. It was purely designed to look at the process - who was involved and how. We had to get ratification from the local Ethics and Research Committee due to new regulations regarding NHS staff and premises. Full details of the study can be obtained from the author. The returned questionnaires gave a total of 65 goal statements, of which 16 (25 per cent) were the statement no goal set. Only one speech and language therapist recorded setting goals always and one stated never. The reasons given for not setting goals are in table 1.
Table 1 Reasons given for not setting goals Reason Given Problems writing a goal statement Stage in rehabilitation Find process difficult Goal is implicit / carried in head Impairment versus functional dilemma Time consuming Forget / slack practice Motivation of patient No. of responses 5 5 4 4 3 2 2 1

GOALS (1): HOW WOULD YOU GO ABOUT IT? GOALS (2): DO YOU HAVE A MASTER PLAN? GOALS (3): YOU WILL KNOW WHEN IT FEELS RIGHT
SARAH EASTON IS NOW TEAM LEADER FOR THE NEW COMMUNITY STROKE REHAB TEAM AT ST MARYS HOSPITAL, MILTON ROAD, PORTSMOUTH, PO6 3AD, TEL. 023 9228 6000 EXT 2510 OR E-MAIL SARAH.EASTON@PORTHOSP.NHS.UK. CAROLINE HAW, SPEECH AND LANGUAGE THERAPIST, COMMUNITY REHABILITATION TEAM, SHEFFIELD, TEL. 0114 2716145, E-MAIL CAROLINE.HAW@NHS.NET. SALLY BOA IS A SPEECH AND LANGUAGE THERAPIST WITH FORTH VALLEY PRIMARY CARE OPERATING DIVISION. SHE ALSO WORKS AT THE AAC RESEARCH UNIT IN THE PSYCHOLOGY DEPARTMENT AT THE UNIVERSITY OF STIRLING (WWW.AACSCOTLAND.COM), E-MAIL SALLY.BOA@STIR.AC.UK OR TEL. 01786 467645. SEE WWW.INTANDEM.CO.UK FOR DETAILS OF GOAL SETTING COURSES RUN BY CATHY SPARKES AND SAM SIMPSON.

Ten Years Time Words & Music by Jonathan Shorten & Gabriella Bobb Copyright Gabsongs (50%)/Universal Music Publishing Limited (50%). Used by permission of Music Sales Limited. All Rights Reserved. International Copyright Secured.

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We grouped factors influencing the goals set into three main themes (table 2).
Table 2 Factors influencing goals set Factors relating to the patient Level of communication ability Patient aims / priorities / concerns Patient insight / experience Patient health Factors relating to family, carers, professionals Motivation of carers / professionals Level of family involvement Cooperation of carers / professionals Multidisciplinary team goal setting process The environment Factors relating to the goal setting process Type of disorder Speech and language therapists experience or perceived ability Time required Impairment versus functional goals To demonstrate progress or lack of it No. of statements 7 3 2 1 No. of statements 5 3 2 2 1 No. of statements 4 4 3 2 2

with the measurement of communication achievement. One therapist commented in a semi-structured interview, goals that are set around communication are sometimes frustratingly woolly or so specific that they loose functional component, therefore patient and therapist question why theyve been set. This leads to difficulties in the multi-professional forum. The most senior therapist interviewed shared her very negative experience of writing linguistically based goals and then having other professionals asking her what they meant. These impairment based goals were written without the patients involvement. The speech and language therapist went through the process of writing a goal, but in fact it was a list of therapy tasks. Goals need patient involvement, with discussion, negotiation and agreement; only that way will they be fully engaged and more likely to succeed. Evidence emerged of variation between newly qualified and more experienced therapists, the latter being much more functionally based, with more junior members of staff focusing on impairment within the individual session. Another aspect to take into account is the patients wishes versus the evidence base. Most patients when asked say they want to speak normally. A dilemma for the therapist is how to translate that into acceptable goals which are measurable and achievable - and useful to all involved with the patient. 4. The type of communication disorder We recorded the main impairment for each goal set, and differences were identified in the interviews. Goal setting in dysphonia and dysarthria were shown to be easier to set due to the absence of language involvement and the acknowledgement of measurable steps, plus the fact that the patient can be a full participant in the goal setting process.

Central to the process

With all of the evidence from the questionnaires and semi-structured interviews, four final themes relating to goal setting with adults with acquired communication disorders emerged: 1. The role of communication in goal setting As speech and language therapists, we know that communication does not just involve the adult with an acquired communication disorder. Everyone must use consistent strategies to continue efficient and effective communication, and evidence has shown that these skills are not always consistently used by all involved with the patient. The communication disability does affect the goal setting process; it requires discussion, negotiation, understanding and agreement. Even with strategies confidently in place, it takes a greater commitment from everyone involved. As one member of staff commented in a semi-structured interview, You need everyone on board to be understanding.were still not that good at actually getting other people on board and understanding what we (speech and language therapists) are trying to do. 2. The patients level of involvement in their rehabilitation The communication disability is not the only factor to influence the patients level of participation. The motivation to work to fulfil their goals is affected by issues as diverse as time since onset of communication disorder, the importance of communication to the patient and their previous language use, depression, visual problems, reduced concentration and insight, plus the level of family and carer support. Time since onset is also affected by current environment. Wressel et al. (1999) wrote that people may become more passive in hospital, even if in a rehabilitation ward. One interviewee described this in relation to a patient who was very passive and not motivated whilst on the rehabilitation ward but on his transfer home was far more aware of what his difficulties were and we have actually been able to.negotiate with him 3. Dilemmas faced by speech and language therapists in the process of goal setting In 1984 Green wrote, Whilst communication therapy is not as amenable to the writing of behaviourally measurable goals as the traditional didactic approach, this need not prevent attempts being made. Twenty years later this study has shown that some speech and language therapists still find this process difficult, with a daunting range of aspects to consider. We are aware of the impairment versus functional aspects, the formulation of the goal being things to achieve rather than things to do, plus difficulties The study found that we must respect the patient and their views, needs and feelings. The type of communication impairment does affect the process, and speech and language therapists continue to have goal setting dilemmas. In our personal lives we dont always achieve all of our to do list; that isnt failure, so neither must it be for our patients. They are central to the process and their drive to attempt tasks cannot be ignored especially if they dont know what they are expected to achieve, or they just dont want to today. Following the study, we held a full day on goal setting facilitated by Cathy Sparkes. This involved all speech and language therapists working with adults, plus invited guests from nursing, occupational therapy, physiotherapy and the local Dysphasic Support. All aspects of goal setting were explored, starting with our own personal plans and how we felt about sharing them which in fact was not that easy. From there we moved onto the process of goal setting especially with the added factor of communication disorder. The day ended with teams looking at how to implement change and build our own confidence with the process. One local issue actioned was to ensure patients are not discharged too early, before they have moved through the various stages of rehabilitation. We need to give them the opportunity to address their goals at various times in various environments. We now realise that our approach to goal setting needs to relate to where the patient is at. It may well be different in the acute stage, with greater team than patient involvement, but it is equally important to continue beyond therapy to Dysphasic Support. We have addressed this recently in Portsmouth, and goal setting has become central for the adult with an acquired communication disorder attending Dysphasic Support. The renewed enthusiasm for goal setting that this research and the study day provided made us realise all that is involved in good goal setting. It is not just the writing of a statement, as it seems when making that to do list. It is integral to good patient care and positive outcomes. It does take time and clear communication, with the full involvement of the patient, but equally it is core to rehabilitation. Does everyone in your team have an understanding of what your patients are aiming to achieve, in what time scale and how best to communicate that to all involved?

Functional
We must support other professionals with all aspects of communication for goal setting, even if that means we do not have impairment based goals, but are supporting functional based goals which are not communication focused. For example, if

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the central goal is for a patient being to be able to access the toilet, the speech and language therapist can play their part in supporting the patient to achieve it. Our role would be to elicit the best way for the patient to communicate the need, and then to ensure everyone is aware of this. This vital functional, non-impairment based aspect of speech and language therapy must be fully recognised. The goal setting process is also of importance in developing the skills of others, both professional and family / carers. One therapist interviewed said, I often set goals.as a way of targeting activity for the patient but also communicating with the multidisciplinary team the areas of priority and potential. Another contributor gave a brilliant example of success with a patients wife. The goal had been fully discussed with the wife and was to use drawing in real context when necessary. But it had not been natural for the wife, and one wonders whether she fully understood her husbands communication problems. She told the therapist that when he had tried all day to communicate something to her, she eventually gave him a pen and paper which led to him drawing a bird, from which she could interpret what he was trying to say. We must also have confidence in our skills and equally must review and reflect on the process so that our skills develop further. In researching this topic I found relatively little, especially in speech and language therapy, to demonstrate what most professionals were doing. Here in Portsmouth we have set up a small group to provide support and advice, and devised new documentation for us all to use. A member of the team has reviewed the multi-professional documentation used for goal setting on a stroke rehabilitation ward, which has resulted in an increase in the communication skills

used on the ward by all professionals and carers. This supports the important fundamental that goal setting is central to all rehabilitation. All of this has begun to increase our confidence in this important aspect of the rehabilitation of acquired communication disorders. When did your team last review this core aspect of rehabilitation? Should it go on your to do list?

Acknowledgements
With many thanks to Cathy Sparks for her interesting and informative day plus advice, and to everyone in Portsmouth who has supported this study. Sarah Easton is a specialist speech and language therapist with Portsmouth City Teaching PCT.

References
Green, G. (1984) Communication in aphasia therapy: some of the procedures and issues involved. British Journal of Disorders of Communication, 19, pp. 35-46. Office of National Statistics (2001) Census. Available at www.statistics.gov.uk (Accessed: 5 July 2005). Royal College of Speech and Language Therapists (1996) Communicating Quality 2: Professional standards for speech and language therapists. London: RCSLT. Royal College of Speech and Language Therapists (1998) Clinical Guidelines by Consensus for Speech and Language Therapists. London: RCSLT. Wressel, E., Oberg, B. & Henriksson, C. (1999) The rehabilitation process for the geriatric stroke patient an exploratory study of goal setting and interventions, Disability and Rehabilitation, 21(2), pp. 80-87.

DO YOU HAVE A

MASTER PLAN?
THE DEVELOPMENT OF A COMMUNITY REHABILITATION TEAM INFORMATION BOOKLET PROVIDED CAROLINE HAW WITH A PERFECT OPPORTUNITY TO FACILITATE AND STANDARDISE GOAL SETTING WITH CLIENTS.
Our interdisciplinary Community Rehabilitation Team has a remit to facilitate early hospital discharge for patients following stroke. There is considerable energy for new ideas and ways of working, providing a very stimulating working environment. A physiotherapy colleague and I decided to produce a patient information leaflet, as all team members felt it would be useful. My particular interest was in something suitable for clients with aphasia in the acute stage after a stroke. At the same time, we were keen to take the opportunity to get away from the notion that, as the health professionals, we would know best. Patients themselves usually know best, since they hold explicit or implicit hopes for their recovery (Clark & Smith, 1998; Wade, 1998). Fostering self-determination in clients can have very positive outcomes, but requires a shift in the balance of power, and finding a way to enable clients to express their hopes (Worrall, 2000). We started to think about the importance of negotiating goals with clients (and carers), both as something to work towards, and as a way of staging their - sometimes unrealistic - long-term goals into more tangible short-term therapy goals. This standard approach would be completely different from our established goal setting process, which had been entirely controlled by therapists, away from patients in our weekly review meeting. There is considerable support in the literature for providing clients and carers with both the information they need (see for example Hangar & Mulley, 1993) and the means to express their goals (see for example Baker et al., 2001). For our rehabilitation team, with its clear-cut resources and interdisciplinary

style, it was practical to combine these two needs into a client-held booklet. The development of the booklet was a lengthy process during which much discussion and many drafts were aired. We depended on dedicated and expert help from secretarial staff. Ideas for content were derived from a variety of sources including the published literature (particularly Stroke Association), colleagues and clients and carers. We agreed it was important to 1.Bring information together in one A4 format 2.Make it of immediate use and not easy to misplace 3.Have a reasonably large text size 4.Have parts that could be customised (such as goal setting and space for extra information sheets). The booklet was developed with clients who had had a stroke in mind. It incorporates picture material (photographs, pictures to illustrate the text and pictures drawn especially to illustrate goal setting) which - although designed to ensure access to clients with aphasia and to provide them with a communication tool - would have appeal to all clients. The written text is simple in style and presented in both paragraph and bullet point form. Colour-coded pages make navigation as easy as possible and may provide extra visual appeal. Having trialled the booklet informally, we had a grand launch in July 2001 with follow-up training sessions to reach all 40 team members. We wanted to ensure that everyone - core staff, administration and clerical, stroke liaison nurses, home care staff understood the importance of the booklet and shared sufficient information to use it. They also needed the opportunity to raise questions, and this process continues via staff meetings. I ran a pilot study to find out if and how the booklet was being used, particularly in relation to goal setting, and to explore what clients thought of it. Ten clients took part. I used purposive sampling to try to capture the range of clients seen by the team in terms of age, sex, disability and geographical area. A week after discharge from the community rehabilitation team, I contacted potential interviewees by telephone. All agreed to a visit at home to discuss the booklet, and I arranged this for a short time after the phone call. Three clients had acquired language disorders, two had acquired speech disorders and two had memory impairment. All ten were back living in their own homes, one of them living alone, and all had been treated by other team members for mobility / activities of daily living issues. I conducted interviews according to a format developed to capture the range of
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Obviously in the long-term you have to be able to be capable so you have to recover more to achieve them. [Short-term] should be the more simple things in life equally as important if not more eg. washing yourself.

questions posed by the study objectives. I piloted a draft structured interview schedule on two clients. The style of questioning was designed to make it accessible to all clients, including those with speech and language disabilities. The interview used open questions, 05 rating scales, multiple-choice questions and closed (yes / no) questions. I used clinical skill to gain as much participation as possible, for example where appropriate the use of single written words. All interviews were within a six week period to control for potential variables external to the individual clients. I examined the data for six themes: Theme 1: Accessibility a) Clients opinions included
Pictures: Theyre self-explanatory - you can understand them. Font size: Yes its good as well because I have a bit of trouble with my eyes. Differrent coloured pages: It didnt really make any difference. Yes thats handy as well, you can pick out different things you want to learn about. General layout: Alright because its not official looking so its easy to read - I found those leaflets (Stroke Association) more scary.

[long-term] Means future, [short-term] means tomorrow. [long-term] Going on how long its taking me no good thinking you can do everything in a couple of months is it so most things will be long-term youd like em to be short-term. I cant get going with that, I cant think about it.

All except one indicated an understanding of these concepts which is broadly consistent with a rehabilitation therapists approach. Some participants added their own perceptions, such as short-term goals being priorities and the more simple things. Some comments demonstrated that a patients understanding of how long recovery may take changes over time, that this understanding only comes with experience and that individuals may need differing amounts of time or therapy to achieve similar levels of recovery. Theme 4: Involvement of clients in goal setting Seven clients had goals written in their booklets. Of the other three, one had goals from a hospital rehabilitation file, one had completed a list of problems but did not feel ready to set goals and one with only physical impairment was clear that my goal is to get back to normality. Participants were asked to reflect upon their own experience; to consider whether they / the team had set the right goals, whether they had worked towards these specified goals and whether they had achieved their target goals. Seven stated that they had set the right goals, worked on the goals set and achieved all or some of the goals set. Although they had no alternative experience for comparison, participants were asked what they thought of being involved in setting goals.
I think its important because they know how they feel you cant fully realise what its like to have a stroke. I would do it together. Its a good. [thumbs up] From my point of view I think its encouraging if you set your own goals and you achieve them it encourages you to carry on.

b) A 05 rating scale gauged the usefulness of each section of the booklet and a formula was used to assign a score (Useful = 4-5, Dont know = 3, Not useful = 1-2, Not applicable = 0). Usefulness

The sections for team description and goal setting scored highest. In some cases, sections of the booklet had not been used. Theme 2: Clients awareness of the purpose of the booklet
Remember I wasnt in a mental condition to accept it, but patients who were were in a position to garnish something from it. Its to write down your progress and also to inform you on strokes and how to go about it. Its to help you to get your use back, to do different things. I think it encourages you to get on with it. Im doing my exercises every day. Goal.

For all except one, the booklet was seen as closely related to the rehabilitation process. Two comments underlined the booklets role in motivating clients. Theme 3: Understanding the rehabilitation process This refers to the rehabilitation process from the therapists viewpoint. Clients sometimes hope to achieve too much too soon or do not have an understanding of the small steps needed to achieve larger scale goals. Participants were asked to say what they understood by the terms long and short-term goals. This was not easy for the communication-impaired participants to respond to.

An important basic theme was setting your own goals (8 out of 10 would do this, one wanted to set goals with a therapist, another wanted a therapist to tell her what to do) and measuring progress against your own standards. Goal setting was experienced as a positive approach. Theme 5: Clients perceptions of outcome Participants were asked to comment on whether the booklet helped rehabilitation, made no difference, or got in the way of it. Nine out of 10 said the information had helped rehabilitation, one that it made no difference. Eight out of 10 said the goal setting had helped rehabilitation. One, a client with memory problems and concomitant distress, felt it might do in time. Another said it had got in the way of rehabilitation. It might be significant that, in addition to a chronic health problems, a degree of cognitive impairment and severe communication disability, both she and her husband presented with a pessimistic view of rehabilitation. Theme 6: Variation in the process With therapists and clients bringing individual styles to the process and the customisable design of the booklet, we expected a degree of variation in how the booklet was used. However, we werent prepared for variation in its presentation (for example, photos not provided, working pages and plastic wallet rarely used). Exploration of the process of goal setting showed great variation: four clients had completed a problem list to inform goal setting goals were written down by either clients or therapists; one had used the picture page to inform goals, which she and the therapist had written together; one had used an extra rehabilitation file in which he had been involved with goal setting in hospital; one could not remember the process; one said she did not use the goal setting part of the booklet [but that she had worked with the team on goals]; one wrote a problem list with the therapist but did not set goals; one commented I was doing it off my own bat and did not have any written goals.

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Further themes emerged that are beyond the scope of this pilot: 1. The timing of the booklet, of information-provision and goal setting 2. The context of goal setting: how does the use of the booklet link with therapists weekly goal setting meetings? 3. The responses to the interviews - due to the nature of their expressive and receptive language difficulties, the aphasic clients were not able to participate as fully as the non-aphasic clients. A future study could focus on a) a greater number of aphasic clients b) the use of extra picture resources to supplement the booklet and c) a more modified, aphasia-focused interview. 4. Responses of the clients with cognitive / memory difficulties. The complexities of the therapeutic relationship are multiplied many times in an interdisciplinary community context. With our team intervention limited to 12 intensive weeks, a booklet such as Whats Your Goal? may be a useful tool for facilitating a quick engagement with the team at a very important time. It may also be a practically useful way of understanding the service provided, allowing clients, carers and therapists a means of talking about the rehabilitation process as a shared event.

Caroline Haw is a speech and language therapist with the Community Rehabilitation Team, Sheffield South West Primary Care Trust.

Acknowledgements
My sincere thanks to colleagues in the Community Rehabilitation Team, Sheffield, my managers and administrative staff, research lead Mark Parker and physiotherapist Morag Hutchinson.

References
Baker, S.M., Marshak, H.H., Rice, G.T. & Zimmerman, G.J. (2001) Patient participation in physical therapy goal-setting, Physical Therapy, May 81(5), pp. 1118-26. Clark, M.S. & Smith, D.S. (1998) The effects of depression and abnormal illness behaviour on outcome following rehabilitation from stroke, Clinical Rehabilitation, 12, pp. 73-80. Hangar, H.C. & Mulley, G.P. (1993) Questions People Ask About Stroke, Stroke 24, pp. 536-8. Wade, D.T. (1998) Rehabilitation is always given a low priority, Clinical Rehabilitation, 12, pp. 1-2. Worrall, L.E. (2000) The influence of professional values on the functional communication approach in aphasia, in Worrall, L.E. & Frattali, C.M. (ed.) Neurogenic Communication Disorders : A Functional Approach. New York: Thieme Medical Publishers.

YOU WILL KNOW WHEN

SALLY BOA ALREADY HAD THE MOTIVATION AND A VARIETY OF TOOLS BUT LEARNING ABOUT A STRUCTURED NEGOTIATION FRAMEWORK HELPED CEMENT HER GOAL SETTING SKILLS.
As a speech and language therapist within a multidisciplinary community rehabilitation team, I have grappled for many years with the theoretical and practical aspects of negotiating realistic, meaningful rehabilitation goals with clients. My interest in goal planning stems from clinical work as well as a research project I undertook in 2003. This examined whether or not the low tech Talking Mats framework (Murphy, 1998) could be used to help people identify rehabilitation goals. A recent study day gave me a further opportunity to consider goal setting frameworks (Sparkes & Simpson, 2005) and to answer some of the questions raised by my pilot study. Goal planning is an essential component of rehabilitation services. According to Schut & Stam (1994, p. 223), Goal setting is a prerequisite for interdisciplinary teamwork. They state (p. 224) that goals must: 1. Be relevant and motivating 2. Express what you want to accomplish 3. Be positively defined 4. Be put in behavioural terms 5. Be explicit and commonly understandable 6. Be attainable and enabling well-balanced planning 7. Enable measurement. Schut & Stam (1994, p. 224) also stress the importance of involving the person in the goal setting process: Something relevant for the therapist may be regarded as completely irrelevant by the patient and / or the other way round. If the patient does not regard a goal as relevant, the team runs the risk that its efforts are in vain; the patient is not motivated to work at an irrelevant goal. The Brain Injury Resource Center (1998) states that The ability to set goals is essential to effective problem solving: and by default, is essential to self management, and self determination. Given that goal planning is essential to planning effective rehabilitation, it is important that all users of a service should be allowed to participate as fully as possible in the process. It can be difficult for people with communication and / or cognitive impairments to do this and often rehabilitation teams rely on their own ingenuity and persistence in order to obtain the views of this group (Wade, 1999, p. 21). My pilot study (Boa & McFadyen, 2003) focused on helping people to consider things

IT FEELS RIGHT

that they wanted to change. The aim was to see if the use of Talking Mats could help people become more involved in the process of goal planning and help them understand what we mean by goals. The Activities and Participation component of the International Classification of Functioning, Disability and Health framework (WHO, 2001) provides us with a comprehensive list of domains which relate to life areas. I used these as a guide for the Talking Mats symbols, and the participants built up a personal picture of specific problems or issues. Initially participants were asked to consider broad topic areas. They then selected topics that they wanted to explore in greater detail. For example, this mat shows that the participants main areas of concern in terms of broad topics were mobility, self-care, leisure, health and using transport:

Using self care as the sub-topic resulted in this mat:

This showed that the participant was concerned with many aspects of self care. Using the mats helped her to think about her many difficulties one at a time. Discussing issues in this way enabled her to think about realistic goals, and also to consider positive aspects of some of the issues. Talking Mats does not provide a written goal plan as such. Rather, it helps people identify problems or issues. Further refinement and negotiation needs to take place if we are to translate these into goals. It does however
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allow us to have a visual record (captured with a digital camera) so that changes in peoples priorities can be monitored. The project demonstrated that Talking Mats is a useful tool that can be used to help people to engage in the goal planning process, but it also left me with a number of questions. A recent study day Goal Negotiation: a shared journey gave me an opportunity to find some answers. Presenters Cathy Sparkes and Sam Simpson are speech and language therapists who have worked for many years within multidisciplinary teams and now share their expertise through a joint venture, www.intandem.co.uk. They described their goal negotiation framework through a combination of formal presentation, practical exercises and discussion which balanced theory and practice. Their broad framework enables us to: * explore issues with our clients; * seek clients opinions right from the beginning; and * offer choices which are relevant and motivating. Goal planning is complex and requires a great deal of skill and flexibility. The key message from Cathy and Sam was that goal planning is a process rather than an end in itself. This can often be overlooked by professionals in busy rehabilitation teams where the emphasis may be on producing written goal plans within certain time scales. By focusing on the outcome - rather than the process - we are doing the people we work with a disservice, and perhaps are not really listening to them. The goal negotiation framework takes us logically through a progression which ensures we dont miss out these important steps, and ultimately results in relevant, motivating and realistic goals which have been negotiated with each individual. Each stage needs to be respected so that the individual can have the time and opportunity to explore their rehabilitation goals and their hopes and aspirations fully. Talking Mats is one example of a tool that fits into the Sparkes & Simpson goal negotiation framework. The study day helped answer questions raised by my pilot study (Boa & McFadyen, 2003): 1. What other methods can we use to help people gain an understanding of rehabilitation goals? By using visual methods creatively to represent what we mean, we can find out what clients see as a goal. Taking time at this stage means we can really listen to what people are saying from the beginning. A main focus of the study day was helping us as clinicians think more creatively about how we present the concept of goals to people. We reflected on what the word goal meant to each of us, and spent time thinking how we might represent this visually. The significant amount of time spent on this made me question whether we spend enough time explaining the concept of goals to the people we are trying to help. This important first step in the goal negotiation journey needs to be continued through the use of symbols, drawings, options and choices as problems are identified and negotiated into goals. 2. At what stage should we be setting goals with people and how long does this process take? Goal negotiation is a continuous process and should not be rushed. One of the first stages is to identify the clients own strengths, problems, aspirations and life goals, then to work out what they might be able to change in the context within which you are both working. Tools such as Talking Mats can be used alongside other methods such as drawing and appropriate analogies for individual clients (for example, going on a journey or thinking of different steps on a ladder). 3. How can we bridge the gap between helping people to identify issues or things that are difficult, and translating these into goals? It can be relatively easy for people to identify problems, but the difficult task is often translating these into goals which are realistic, meaningful and can be measured. Relating problems to real life contexts - and helping clients to see what they want to change and what they are happy to settle for - can help them to prioritise and sort out the precise areas they want to work on. This gives both client and therapist a clear path and direction. 4. How can we help clients to understand and relate to the actual written document (the goal plan)? With goal planning providing direction for therapy, it is essential that our clients can relate to and understand the written document, so that it can be referred to and changed during the therapy process. Engaging people in the process of setting goals from the very beginning exploring the meaning of goal, thinking about longterm and short-term goals, considering the steps needed to get there - will ensure that the written document will be relevant. Tools such as lifestyle grids (Jeffers, 1987), Mind Maps and Talking Mats can help us produce visual materials which are meaningful and have been constructed jointly with our clients. This results in a sense of common understanding, ownership and empowerment. Goal planning is a process that takes time, effort and skill. The goal planning framework (Sparkes & Simpson, 2005) provides us with a structure to ensure that the multidisciplinary team is involving people in a way that they can understand, right from the beginning of rehabilitation. Using the framework helps us to consider individuals and the situations and environments they are in, helps them to identify strengths, problems, aspirations and priorities and ultimately allows goals to be negotiated. Within this framework, a number of tools can be used, as well as our skills of negotiation. These tools, along with structures such as the International Classification of Functioning domains (WHO, 2001), ensure we no longer need to rely on our ingenuity and persistence (Wade, 1999), but that we can draw from a variety of resources. By doing this we can embark on the journey of negotiating goals with our clients, starting from a point of shared understanding and partnership. Sally Boa is a speech and language therapist in Forth Valley and at the AAC Research Unit, University of Stirling.

References
Boa, S. & McFadyen, L. (2003) Goal Setting for People with Communication Difficulites, Communication Matters 17(3), pp. 31-33. Brain Injury Resource Center (1998) Goal setting. Available at: http://www.headinjury.com/goalset.htm (Accessed: 3 July 2005). Jeffers, S. (1987) Feel the fear and do it anyway. London: Arrow Books. Murphy, J. (1998) Talking Mats: Speech and language research in practice, Speech & Language Therapy in Practice. Autumn, pp. 11-14. Schut, H.A. & Stam, H. J. (1994) Goals in rehabilitation teamwork, Disability and Rehabilitation 16(4), pp. 223-226. Sparkes, C. & Simpson, S. (2005) Goal negotiation: a shared journey: Adult Acquired Disorders (Scotland) Special Interest Group study day. Perth 10 February. Wade DT. (1999) Goal Planning in Stroke Rehabilitation: How?, Topics in Stroke Rehabiltation 6(2), pp.160-36. World Health Organisation (2001) ICF: International Classification of Functioning, Disability and Health. Geneva: WHO. Available at: www.who.int/entity/classifications/icf/en/ (Accessed: 19 July 2005).

Resources
* Mind Maps - see www.mind-map.com * Talking Mats, see www.talkingmats.com

resources
HPC website
The Health Professions Council has overhauled its website to make it easier for professionals and members of the public to use. www.hpc-uk.org

Learn from the experts

A series of pamphlets written by and for young people with an acquired brain injury - Learning from the experts - is downloadable free at www.cbituk.org.

Vocabulary software

LDA Language Cards Interactive is a series of basic language skills CD-ROMS for PC and Mac. It includes three programs - Nouns, Verbs, Prepositions & Adjectives - to help pupils build and consolidate a strong vocabulary. Speech or text can be switched off and there are four levels of difficulty. www.sherston.com

Photodynamic Therapy

A new charity aims to raise awareness of and funds for research into Photodynamic Therapy for cancer. Pre-cancer and early cancer of the mouth are among the conditions thought to be most suitable for this type of treatment. www.killingcancer.co.uk

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SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005