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GOAL NEGOTIATION (2)

Whose goal is it anyway?


Part 2: Getting the process right
In the second of a four part series, Sam Simpson and Cathy Sparkes offer a flexible framework for a goal negotiation process that takes clients, families, therapists and teams from the first meeting through to preparation for discharge in acute, rehabilitation and community contexts.
n this series we hope to challenge and develop your understanding and practice of client-centred goal negotiation. In our first article we defined frequently used terminology and considered the key principles that underlie effective client-centred goal negotiation. In this second article we examine the actual goal negotiation process. Some of you will work in successful interdisciplinary teams or as a single discipline where the goal negotiation process is well established and understood by professionals, clients and families. Others will be working in a team or as a uni-professional where the idea of a framework for goal negotiation feels far from reality. We invite you all, however you are currently working, to assess the level of client involvement within your service and to reflect on the proposed process outlined in figure 1. This process has been borne out of many years of clinical experience and commitment to client-centred goal negotiation as the backbone of cohesive interdisciplinary team working. It is the result of considerable client, family and multi-professional consultation and review, which has been further influenced by the cross-fertilisation of different theories and research into goals across a range of disciplines. We will describe each step in loose terms, but ask you to bear in mind the service within which you work. Consider this a flexible framework to be adapted in accordance with your work context, not something to be applied rigidly and unquestioningly. For ease, we have divided the process into three phases: READ THIS IF YOU WANT THERAPY TO BE MORE CLIENT-CENTRED MEANINGFUL FOCUSED

Cathy and Sam

This can take a variety of forms: face-to-face in either a 1:1 or group therapy session, through the use of information leaflets, handbooks or information boards. Time allocated to explaining the goal negotiation process enhances a clients knowledge of the service they have entered into and how that service is delivered in addition to its specific remit and boundaries. This is integral to managing both client and professional expectations from the outset, clearly delineating roles and promoting the clients engagement in rehabilitation. 4. Initial goal exploration The next stage involves an open exploration of lifestyle issues, wants and aspirations with the client and their family. It is a loosening process, enabling the client to identify broad life domains and priorities at that point, from which potential rehabilitation goal areas can be established. This is a crucial stepping stone to eliciting more focused client-centred goals. This preliminary discussion can be facilitated by the keyworker or by an allocated team member for and on behalf of the team. It takes the form of a supported conversation with visual frameworks such as mindmaps and time lines that can then be shared with family and other team members to promote further discussion.

be negotiated in order to avoid unnecessary duplication and also for a key worker or coordinator to be assigned, if appropriate. Close cooperation and communication is encouraged as professionals can share information regarding who is doing what, how frequently and in what location. 2. Identification of strengths, needs, wants and issues The next step involves drawing up a list of the clients strengths, needs, wants and issues on admission. The multidisciplinary team provides evidence in support of the clients viewpoint and also to supplement this, through ongoing assessment and the start of intervention. This is an important stage as it ensures the client and their family remain at the centre of the information gathering process and reminds the team to keep documentation a priority. To draw up this list, sessions with the client and/or their family can be held with one discipline or with two or more together depending on the issues to be discussed. Assessment review and feedback of results can also be an important part of this process. 3. Explanation of the goal negotiation process This stage is often omitted as professionals frequently assume that clients and their families are familiar with the processes involved in goal planning and negotiation. However, this is invariably not the case, and it is important to provide regular accessible information about the actual goal negotiation process.

B. ONGOING PHASE
5. Developing the prerequisites for goal negotiation A clients capacity to negotiate meaningful goals will depend on their individual personality, life experience, degree of emotional stability, level of cognitive understanding, and capacity for mature reflection, self-understanding and decision making. It is important to recognise that goal negotiation is a complex skill and not to expect that all clients will be able to engage in the process readily. Indeed, you may need to allocate time to foster the foundation skills involved in goal negotiation and to establish a clients potential for change. While we believe it is crucial to respect a clients pace

A. INITIAL PHASE
1. Assessment liaison This first step refers to the point when a client enters your service. Ideally, each team member will have had the chance to meet with and informally assess the client and their family, and is consequently ready to share their preliminary thoughts and concerns regarding the clients admission with other members of the team. Liaison with all professionals involved at this early stage allows for roles to

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GOAL NEGOTIATION (2)


1. Assessment liaison A. Initial phase 2. Identification of strengths, needs, wants and issues 3. Explanation of the goal negotiation process 4. Initial goal exploration 5. Developing the pre-requisites for goal negotiation B. Ongoing phase 6. Further goal exploration as required 7. Goal negotiation and elicitation 8. Initial and ongoing goal negotiation meetings 9. Final goal negotiation meeting C. Preparation for discharge 10. Scoring / audit 11. Documentation including report Figure 1 Goal Negotiation Process

helpful. One commonly used is: A = Achieved P/A = Partially achieved N/A = Not achieved. Additionally, a set of variance codes can give an indication of why a particular goal was not achieved. These are often divided into broad categories such as those relating to the client (eg. unwell), the healthcare professional (eg. therapist off sick), resources (eg. equipment not available). The scoring systems can help the client to understand the reasons why a certain goal was not achieved and can also be used for audit purposes. Regular, well documented goal review meetings are an essential part of maintaining a focus for rehabilitation and a method for reviewing the effectiveness of intervention. The multidisciplinary team needs to remain clear as to the purpose of the goal review meetings and determine the need for separate meetings such as case conference or discharge planning as appropriate.

and readiness to formulate their own therapy goals and direction, we appreciate this can be at odds with lean working principles. Investing time in supporting the development of the prerequisite skills involved in goal negotiation will in turn increase a clients engagement in the therapy process through greater selfknowledge, a more solid understanding of therapy (possible benefits, limitations and the role they have to play) and a greater appreciation of their personal potential. The necessary prerequisites for goal negotiation can be developed through joint sessions with family/friends and the client, targeted assessment and review, video feedback, 1:1 and group community visits, education sessions, re-explanation of the goal negotiation process, task analysis, and exploration of the pros and cons of a particular behaviour. 6. Further goal exploration Essentially this involves repeating stage 4 as appropriate and offering the client more time to explore and establish potential goal areas and priorities. They can then progress to the formulation of more focused goals. 7. Goal negotiation and elicitation This stage can be considered a tightening process. The information gathered from the goal exploration sessions (A4 and B6) is further discussed with each discipline involved in order to establish more focused client-centred goals. Frameworks that can usefully facilitate this include prioritisation, rating scales and steps, and option appraisal. The contract comprises a shared agreement across the team on the focus of therapy within the context of the service offered over an agreed time frame. The goals negotiated structure the rehabilitation process and provide the foundation for therapy across the entire team. Furthermore the clients high level of involvement in negotiating this management plan serves to enhance

their commitment and understanding of the process. The keyworker or an allocated team member is tasked with coordinating and disseminating the final document detailing all of the agreed goals. This needs to be in a format that is accessible to the client and their family as well as the team. 8. Initial and ongoing goal negotiation meetings Regular goal negotiation meetings provide a useful forum to agree on and review all longterm/discharge goals, short-term goals and plans of action. We use the term meeting to indicate a more formal opportunity to discuss the goal planning process. Who actually attends may vary across time according to the individual client and structure of the team. At the very least it will involve the client and a key professional, however family and friends (at the clients request) may also be present, as well as one or more members of the multidisciplinary team. While the meeting can take place in a variety of locations depending on where the client feels most comfortable - their own home, a lounge, a more formal meeting room - it is important that the environment is quiet and undisturbed, and signals the level of importance given to the discussion. These meetings focus solely on formalising the goals negotiated, intervention plans and roles across the team. Clear documentation of goals and the decisions made in each meeting is essential for the client, the family and all healthcare professionals, especially if not everyone is present. The frequency of meetings (weekly, bi-weekly, monthly) to review all subsequent goals and dates/times need to be agreed by everyone involved. The frequency negotiated will also need to balance the realities of caseload/time pressures for the team with the need to keep the focus and momentum for the client. When each goal is reviewed a system of scoring (agreed by and clear to all) can be

C. PREPARATION FOR DISCHARGE


9. Final goal negotiation meeting In preparation for discharge this final goal negotiation meeting should include some or all of the following so the client and their family have the opportunity to celebrate successes and identify future paths: A review of the most recent long-term and short-term goals A review of the overall intervention package An evaluation of the intervention process from the clients perspective An opportunity for endings from the current service and possibly introductions to the next service The identification of possible future goal areas. 10. Scoring / audit As referred to in B8, a scoring system can be of help to the client, their family and the service as a whole. As with all aspects of this process, it is important that the system works well for the context within which it is used. 11. Documentation including report Clear written communication is essential throughout a clients admission, both for the team and for the client and their family. This can take a variety of forms including the use of an assessment liaison checklist to standardise the process, written information for the client about the goal planning process, multidisciplinary or single discipline notes, a specific goal planning section within the medical notes, written copies of goals or goal areas in a format accessible to the client, written minutes of meetings, variance codes. It can also be beneficial to use the goal negotiation process as a framework for a single discipline/multidisciplinary team report when referring on.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2011

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GOAL NEGOTIATION (2)

D. DIFFERENT SETTINGS
This goal negotiation process can be used flexibly depending on the setting you work in. Here are some of our ideas for different service areas: a) Acute Therapists in acute settings often report difficulty translating the goal negotiation process due to the status of clients and the short time they remain within the service. We recommend prioritising the early stages, in particular gathering information about the client from a team perspective through interviews, single or joint assessments, and the use of pre-injury questionnaires. Robust documentation systems and lines of communication assist further. Family and friends are often readily accessible and can usefully be involved to formulate a comprehensive picture of the clients past and present situation. Clear feedback, information and education opportunities will promote client self-awareness and development of the prerequisite skills for goal negotiation. For those who remain longer in the acute setting, establishing a transparent prioritisation system enables therapists to identify clients who are appropriate for the subsequent stages of goal negotiation. Thus it may be possible to negotiate some short-term (2 to 5 day) impairment or activity-based goals under a broader goal area with specific clients. Look for flexibility and any opportunity for dialogue around potential goal areas. Encourage links with real life to facilitate the elicitation of meaningful goals (looking through a favourite magazine together, a cup of tea at bedside jointly with a family member, a visit to the coffee shop, garden or local shops). As and when a client transfers onto the next service, this will be invaluable. When therapists offer information to clients about any post-acute services it can be useful to introduce the concept of goal negotiation and the integral role that it will play in rehabilitation. Interdisciplinary working and a shared commitment to the goal negotiation process can be supported by having an allocated goal negotiation coordinator, who ensures induction and training programmes to all staff and the establishment of working groups to support its ongoing development.

b) Rehabilitation Whilst it can be helpful for some clients to have time away from their home to reframe their present situation, skills and abilities, for others an inpatient rehabilitation setting is artificial and overly institutional. Regular links with real-life contexts (sessions over lunch or coffee, group opportunities, community visits, home visits) facilitate the elicitation of meaningful goals and provide clients with tangible ways to move forward. Take a moment to reflect on why clients come to your rehabilitation service, and whether the timing of admission is something you or they have any choice over. Consider also how time is framed and time boundaries determined. Does your service offer a standard time-limited contract (6 to 12 weeks) or are more discrete, flexible packages negotiable (an assessment package, a review package, an individual or group therapy package, a graded admission, a graded discharge), thereby allowing therapy to be adjusted in accordance with a clients readiness for change and the focus of therapy? To what extent is the service you offer at a multidisciplinary or single-discipline level really tailored to what your clients want and need across time? Interdisciplinary working, shared commitment to the goal negotiation process and flexibility are all key components to any rehabilitation service and enable clients to make the most of their time with you. It is possible for multidisciplinary team members to work in series as opposed to in parallel to cater for differences in a clients readiness to change. We recommend the allocation of a goal negotiation coordinator, the development of induction and ongoing training programmes as well as multidisciplinary working groups and regular consultation with clients, their families and friends. Attention also needs to be given to the development of robust documentation systems and lines of communication in addition to clear and timely information exchange on transfer. These systems and approaches in the rehabilitation environment truly serve to offer the client more person-centred, flexible and timely interventions. c) Community When clients leave the confines of an institution to embark on life back in the real world, they are entering a context that arguably has the greatest meaning to them. Working within the community has the advantage of increasing

the range of locations where therapy can take place (at the clients own home, in a coffee shop, pub, day centre or multidisciplinary outpatient service), thereby promoting links with real life and the negotiation of meaningful goals. There is also often greater flexibility and availability to involve family and friends in therapy. We recommend flexible frameworks for service delivery over standard time-limited contracts, as this allows for structured agreements related to the duration and focus of any particular therapeutic relationship. Similarly, interdisciplinary working in series as well as in parallel also allows for greater flexibility and timeliness of intervention across the team. The unpredictability of the community context and personnel creates particular challenges for therapists and has significant implications for the infrastructure and process of goal negotiation across a team. Consequently, a cohesive goal negotiation process agreed by all professionals in addition to robust documentation systems and lines of communication are all key. Clear information on the service especially its remit and boundaries and end points is also critical. Having an allocated goal negotiation coordinator to develop induction and ongoing training programmes as well as a multidisciplinary working group also supports the ongoing development and review of the goal negotiation process.
PRACTICAL ACTIVITY: Your goal negotiation service Identify aspects of the proposed goal negotiation process that are in line with your existing service, and consider possible development ideas. Remember the process is a flexible framework that can be used differently according to the service you are working in and the client you are working with.

In our next article, we will focus on the clients voice through exploring a 6-stage model of readiness to change, and on the actual goal negotiation conversation in a range SLTP of contexts. Sam Simpson (email sam@intandem.co.uk) is a specialist speech and language therapist and trainee counsellor. Cathy Sparkes is a specialist speech and language therapist and counsellor. Together they are intandem (www.intandem.co.uk).

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SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2011

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