GOAL NEGOTIATION (1)

Whose goal is it anyway?

Part 1: A strong foundation

READ THIS IF YOU WANT THERAPY TO BE MORE CLIENT-CENTRED MEANINGFUL FOCUSED

In the first of our new four part series, Sam Simpson and Cathy Sparkes unpack the terminology, different perspectives and key principles that underlie effective client-centred goal negotiation, and share their strategies to ensure the timing and tempo is driven by the client rather than external pressures.

e very much value the opportunity to bring the complex and diverse topic of client-centred goal negotiation into the public arena for discussion and debate. We are two clinicians with long and varied careers in the fields of brain injury (both) and stammering (Sam), for whom client-centred goal negotiation has played a central role at both unidisciplinary and interdisciplinary levels. Having lectured and consulted clients, families, professionals and students since 1993 in this field, it is highly apparent that the concept means different things to different people. In this first of four articles we will cover terminology, review different perspectives to goal negotiation, consider its relevance to client-centred working, and introduce the four key principles. In the second we will present a goal negotiation process along with a theoretical model of change that further frames this process and delineates flexible goal negotiation practices across acute, rehabilitation and community settings. In our third article we will explore the actual goal negotiation conversation, including case examples from a range of contexts. Finally, we will consider goal writing skills, represent the client voice and reflect on clinicians service developments that we have supported in recent years. This first article includes two practical tasks, which are suitable for you to do alone, with a colleague or as a team. Please now complete task 1 before continuing with the article. A. TERMINOLOGY We anticipate your reflections will highlight the broad range of meanings that are readily associated with the term goal from more professional connotations such as a target, something to work towards and outcome, to include more of a laypersons understanding relating to the goals scored in football, where there is a strong association with winning and losing, success and failure. They will also hopefully have highlighted the many different parameters of goals that people set themselves from the looser, more aspirational and potentially unrealistic personal goals that may only go acknowledged privately, through to those that we are willing to go public with and share, right to the more concrete, smaller, routine-based actions that we readily write and re-write in a daily to do list. Thus some goals are

Task 1: What do you understand by the term goal? Take 10 minutes to consider and write down your responses to the following questions: What do you understand by the term goal both in and outside of work? To what extent do you as an individual have hopes, dreams, goals? In what ways do you try to achieve them? Who / what do you turn to in order to move your life forward? When do you know the time is right to take the first step towards your hopes, dreams or aspirations? Do you plan / negotiate / set yourself goals either implicitly or explicitly? Then, either on your own or with a colleague with whom you feel comfortable, discuss and reflect on your answers.

likely to be quite specific and clearly articulated, whilst others are likely to be more vague and difficult to explain. Some will feel very possible and easily achievable, whereas others will be set year in year out, even in the knowledge that they are unlikely ever to be achieved. We also predict that different styles and personal preferences to goal negotiation will become apparent. Some of you will enjoy the task of defining clear personal goals to work towards, whereas for others the process and sense of direction will be more important than whether or not you actually achieve the final goal. Some of you will also enjoy having a focus and challenge to work towards over an extended period in anticipation of the feelings of achievement this will bring about. For others, the risk of failure and having to manage potential disappointment will be enough to deter you from setting goals outside of the day-to-day routine. All of this serves to highlight the diverse meanings, personal styles and preferences people bring to the goal negotiation table, and the importance of exploring this from the very outset to ensure a shared language and understanding. B. Perspectives and client-centredness Each person you work with, either as a client or family member, will have their own unique views and experiences of goals. It is vital to have this conversation early on, and to be proactive in engaging clients in a dialogue around what is meant by the terms and concepts that are going to be used. In this way, right from the start, goal negotiation provides a framework to develop a shared language that is embedded in the world of the client. Thus, in essence, it is truly client-centred. This initial conversation helps to promote a balance of power in the therapeutic relationship. Having

a goal negotiation process which can be used flexibly and tailored individually offers a sense of direction, particularly if the world is or has become chaotic for the client and their family. C. Key principles 1. Client involvement By client we refer not only to the person with communication difficulties, but also to their relatives, friends and carers. Client involvement at all stages and levels of goal negotiation is essential as, when the client remains central to the process, they gain insight into therapy, their recovery or development, and the entire enablement process. It will also give them some control and choice at a time when they may feel overwhelming powerlessness. In addition it provides opportunities for the review and demonstration of progress (or not). Goal negotiation can therefore offer the therapist a vehicle for increasing client commitment to and engagement in their therapy, for preparing transitions between services, and ultimately for facilitating client autonomy. 2. Identification of strengths and problems The assessment process enables each discipline and the multidisciplinary team to determine early on each clients strengths, problems, hopes and aspirations. This provides the team with information about potential areas of focus with the client. Involving the client in identifying their strengths and areas of difficulty allows for assessment of their level of self-awareness and knowledge of the implications of their condition. This is an essential stepping stone in engaging the client in directing their own management. Once all areas have been investigated and discussed, the next step is to ensure that appropriate resources within the regular multidisciplinary

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SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011

GOAL NEGOTIATION (1)

team or the wider service are in place. This helps the client to understand who they can turn to, and for what support. 3. Multidisciplinary team involvement Working in the field of neurorehabilitation, there is an inherent complexity to each individual clients needs. To work with this client group to best effect, a true skill mix, excellent collaboration and respect for areas of overlap and (in turn) carryover between professionals are needed. Such effective interdisciplinary team work can be facilitated by efficient lines of communication, including formal and informal meetings, clear documentation, and a shared understanding that goal negotiation is the very foundation of neurorehabilitation. Also, to ensure that the goals negotiated with each client are personally meaningful and relevant, they need to be negotiated not only between the client and a single discipline, but with the client and the entire multidisciplinary team. We are aware that not all of you have easy access to any or all multidisciplinary team members in your respective settings. However, wherever you are based, it is always helpful to be linked or communicating with relevant professionals, whether in the NHS, voluntary sector or social services. This invariably requires a commitment to making contact with these services and being proactive in fostering ongoing relationships. 4. Goals We are very much of the opinion that goal negotiation is not purely about the setting and writing of goals, and in fact consider the actual writing of the goal to represent the final part of a complex process. It is also important to remember that not all goals negotiated have to be achieved indeed, in life we rarely achieve everything we set out to do. It is important, from the very outset, to ensure that clients do not perceive goals purely in terms of success and failure, but can appreciate there is potentially more to learn from not achieving and subsequently revising a goal than from achieving it the first time. In fact, research has demonstrated that, in order to set goals at an appropriate level of challenge for a client, optimally an 80 per cent success rate should be aimed for (Johnson, 1997). For the goals negotiated to be intrinsically motivating they need to be client-centred. In addition, for a client to experience the full impact of goal achievement the goals need to relate to a change in behaviour. A useful conceptual framework for negotiating and writing goals is shown in figure 1.
Figure 1 Framework for negotiating and writing goals WHO Will be doing WHAT Under what CONDITIONS To what DEGREE of success Within what period of TIME e.g. John will go to the cinema with a friend (James or Susan) at least once a month for the next three months Task 2: To what extent do you embrace the core principles in your goal negotiation practice and service? Take 10 minutes to consider and write down your responses to the following questions: To what extent do you truly involve clients in planning and evaluating the therapy you deliver? To what extent do you involve clients in the assessment process and determining what their strengths, difficulties, wants and priorities are? How interdisciplinary is your goal negotiation practice and service? How proactive are you at making links with any professional or service a client becomes involved in (such as the voluntary sector) if you generally work in isolation? How much time do you allocate to negotiating goals with your clients? Does the culture and philosophy of your service support client-centred goal negotiation? What terminology do you use in relation to goal negotiation? How consistently and transparently is this terminology used across clients and professionals? Then, either on your own or with a colleague with whom you feel comfortable, discuss and reflect on your answers.

In many settings goals are typically divided into two time frames, short and long. The exact length of these time frames will vary according to the work context with a short-term goal being achievable within one week to one month, and a long-term goal potentially spanning four weeks, six months or longer in some contexts. a) Long-term (discharge) goals We define long-term goals as interdisciplinary goals which reflect the clients potential lifestyle or level of participation (WHO, 2001) on discharge. One or more of the following domains are often included in long-term goals: Home Leisure Social relationships Occupation / self-occupation. Often clients need reflection time to identify meaningful long-term goals, and this requires sensitivity and patience on the part of healthcare professionals. Indeed, it is important to remember that any discussion about longer-term outcomes provides a platform for enhancing the clients understanding of their condition and potential for change, for managing their expectations, and for exploring issues such as dependence, support needs and networks, role changes, losses and the rewriting of personal narratives. Consequently it is important not to underestimate the emotional load of such discussions and the need to respect and be sensitive to the clients pace and process. This is invariably in direct conflict with NHS time pressures, lean working principles, ever increasing throughput targets and emphasis on data collection to demonstrate clinical effectiveness. Such factors often result in therapists feeling the need to negotiate goals very quickly in order to get on with the actual therapy. This rush to define a clear clinical outcome frequently results in little time and attention being given to the clients process. True collaboration and negotiation are sidelined and the actual writing of the goal becomes a professionally driven pen and paper exercise. b) Preliminary goal area vs. long-term goals We strongly advocate against rushing to write long-term goals for the sake of it. Instead we propose using a looser concept provisionally, which we have termed a preliminary goal area. This might be to return home, get out and about or meet up with friends more

regularly. A preliminary goal area provides the client and the team with a sense of overall direction under which short-term goals can be written and worked on for an interim period until a more specific long-term goal has been negotiated. This flexible process will ultimately enable the formulation of a more meaningful, client-centred long-term goal as the client gains an understanding of the therapy process, their own priorities and potential for change. c) Short-term goals By contrast, short-term goals represent a breakdown of a longer-term goal into smaller, more manageable steps (for example, John will read the Stroke Association booklet on continence and discuss it with his named nurse and wife at least once in two weeks). It is important that all short-term goals have a linear relationship with the long-term goal they relate to. Typically short-term goals are set at the level of activity and impairment (WHO, 2001) and are a combination of multidisciplinary team and single discipline goals. d) Plan of action In addition to a clients long-term and shortterm goals, other activities or roles are carried out by healthcare professionals on behalf of or for the client in support of their goals, and can often go unnoticed. We call these plans of action. Examples include organise purchase of bath board and liaise with Social Services. It is important to distinguish this professional activity from the goals carried out by the client and / or their family, and also to make sure they are documented clearly and assigned to a particular member of the team. Please now complete task 2. We hope your reflections will form a strong foundation for you to get the most out of this series. 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 SLTP are intandem (www.intandem.co.uk).
Reference Johnson, M. (1997) Outcome measurement: towards an interdisciplinary approach, British Journal of Therapy and Rehabilitation 4, pp.472479. Resources An explanation of lean thinking is at www.lean.org/ World Health Organisation (WHO, 2001) International Classification of Functioning, Disability and Health (ICF), www.who.int/classifications/icf/en/index.html

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