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Clinical Rehabilitation 2009; 23: 291–295

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
292 Editorial

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.

Goal setting – theory


Why set goals?
The setting and use of goals is a complex interven-
Why should the reasons behind rehabilitation tion. There are many components, and the rela-
treatments be made explicit? The benefits of set- tionships both between the separate components
ting goals in the management of organizations and between the process of goal setting and the
have been investigated extensively2 and it has eventual outcomes are likely to be non-linear and
been shown that setting a person goals increases unpredictable. In this situation it is important to
their behaviour change, presumably through use theory to guide all actions and decisions as far
increasing motivation (the desire to act in a parti- as this is possible.6 In reality the relationship
cular way). There is no particular reason to doubt between theory and practice is recursive: theory
its effectiveness in patients participating in will suggest or guide actions and research; and
rehabilitation. the results of actions and research will confirm,
However, it is far from certain that the time and refute or alter the underlying theory.
effort expended in a detailed and formal goal-set- The theoretical underpinning of goal setting in
ting process is necessarily better than simply set- rehabilitation has not been well researched, and
ting a goal. Indeed one paper in this issue that tends to depend upon theories used in other con-
reports on a randomized controlled trial of three texts.5 This issue has one paper7 reporting on a
approaches to goal setting specifically raises the systematic review of the theories that underlie
issue of whether a formal process is better than the practice of goal setting in rehabilitation, and
simply using goal attainment scaling.3 a second paper comparing the use of two different
Before dismissing the goal-setting process, it is theoretical approaches to setting goals.2 It seems
important to consider whether the process of likely that different aspects of the process will
setting goals in rehabilitation has several other depend upon different theories, but at present
purposes over and above motivating the patient. it seems likely that existing theories should be
The shared setting of explicit goals by a group reasonably applicable.
of people should ensure both that all actions
undertaken by each individual are contributing
towards the overall goal and that important,
necessary actions are not overlooked. Team The goal-setting process
effort in setting goals should facilitate both the
efficiency (through cooperative activity) and the Whenever a patient’s problems are sufficiently
effectiveness (through not omitting any important complex to require the involvement of a two or
actions) of rehabilitation. more people from different professions and/or
Third, having a goal allows the effectiveness of the process is continued for more than a few
the rehabilitation process to be monitored. This is days, then a formal goal-setting process may be
particularly important because often it is unknown needed to derive a set of goals that:
which of several interventions might help (if any)
and it is important to stop ineffective actions as  motivate the patient;
soon as it is clear that they are not having the  ensure that individual team members work
desired effect so that an alternative way of towards the same goals;
Editorial 293

 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
294 Editorial

Table 1 Some of the words associated with each letter of the acronyms SMART and SMARTER in the
context of goal setting

S Specific, significant, stretching, simple, stimulating, succinct, straight forward,


self owned, self managed, self controlled, strategic, sensible
M Measurable, meaningful, motivational, manageable, magical, magnetic,
maintainable, mapped to goals
A Agreed upon, attainable, achievable, acceptable, action-oriented, attributable,
actionable, appropriate, ambitious, aspirational, accepted/acceptable, aligned,
accountable, agreed, adapted, as-if-now
R Realistic, relevant, reasonable, rewarding, results-oriented, resources are adequate,
resourced, recorded, reviewable, robust, relevant to a mission
T Time-based, timely, tangible, trackable, tactical, traceable, toward what you want,
and many starting with ‘time-’ (e.g. -limited, -constrained, etc.)
E Ethical, exciting, enjoyable, extending, evaluated, engaging, energizing
R Recorded, reviewed, rewarded, realistic, relevant, resourced, research-based

And that with patients. It may well be useful as a sensitive


and specific outcome measure17 in randomized,
the suggested acronym doesn’t mean that every controlled trials provided the goals are set by
objective written will have all five criteria. people before allocation and are scored by people
unaware of group allocation. But I am much less
If one of the originators of the acronym (who certain that it is useful as a routine measure of
used the word attributable for ‘A’) was flexible, outcome in daily clinical practice. What is clear is
then perhaps modern practice should also be less that judgements about the success of rehabilitation
rigid in its adherence to being SMART. must not be based on goal attainment scaling as
it becomes demotivating2 and liable to gaming.

Goals and evaluation


Goals and resources
One potential benefit of setting specific patient-
centred goals is that it might allow quantification Finally one paper21 raises another very important
of outcome in each case, avoiding the need to use issue that arises from some of the words in the
the same single measure of outcome in all patients. table (‘resources are adequate’ and ‘resourced’).
This approach is known as goal attainment scal- Specifically, Levack asks to what extent people
ing, a technique for quantifying change in indivi- participating in the process of goal setting may
dual patients first used in learning disability and alter the goals they set, usually to a lower level,
psychiatry16 but also used in rehabilitation.17 because setting a higher goal may use more
This issue has several papers that discuss or resources than are considered reasonable.
investigate goal attainment scaling in rehabilita- He uses one approach to ethical problems –
tion.3,18,19 Readers should note that there is utilitarianism – and he argues that in practice
considerable debate about the actual scoring. using an utilitarian analysis could well justify set-
One paper18 puts forward the scoring system ting goals that consume more resources. Thus ethi-
(and also gives access to an Excel spreadsheet for cal organizations responsible for rehabilitation
practical use), but the theoretical basis is chal- should be pressing for adequate resources rather
lenged within the conference report5 and practical than constraining the goals set. Unfortunately
problems are also discussed in other papers.15,19 political pressures usually favour almost any
My own conclusion based on one of the papers in other part of health care and the lack of strong
this issue3 and also on a systematic review20 is that evidence to support his argument (which may well
using the process of goal attainment scaling is prob- be valid) means that we may remain underre-
ably useful in the clinical practice of setting goals sourced for a while longer.
Editorial 295

Conclusion 6 Craig P, Dieppe P, Macintyre S, Michie S,


Nazareth I, Petticrew M. Developing and evaluat-
ing complex interventions: the new Medical
Goal setting is and will remain a central feature in Research Council guidance. BMJ 2008; 337: a1655.
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tency of any member of a rehabilitation team. applying psychological theory to setting and
However there are at least three major research achieving rehabilitation goals. Clin Rehabil 2009;
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synthesis for use in rehabilitation of the large body 8 Maslow AH. A theory of human motivation.
Psychol Rev 1943; 50: 370–96.
of evidence concerning goal setting in all areas
9 Davis AM, Davis S, Moss N et al. First steps
including sports science and business management towards an interdisciplinary approach to rehabili-
as well as the smaller amount of evidence in reha- tation. Clin Rehabil 1992; 6: 237–44.
bilitation. Second, studies in rehabilitation are 10 Rapid BI. How to write SMART objectives and
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In the meantime we should negotiate and set 2009, from: http://www.projectsmart.co.uk/smart-
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completely SMART, and some goals may not be 13 Businessballs. Acronyms and abbreviations.
SMART at all. Goal attainment scaling may be an Accessed 24 January 2009, from: http://www.
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Derick T Wade attainment scaling; a practical guide. Clin Rehabil
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16 Kiresuk TJ, Sherman RE. Goal attainment scaling:
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