PURPOSES AND MECHANISMS OF GOAL PLANNING IN REHABILITATION NAMEN IN MEHANIZMI DOLOČANJA CILJEV V REHABILITACIJI
Diane Playford, Professor of Neurological Rehabilitation
University of Warwick, UK
Povzetek
Določanje ciljev je definirano kot proces razpravljanja in pogajanja, pri katerem pacient in strokovnjaki iščejo ključne prioritete za posameznika ter se dogovorijo do katere ravni izvedbe bo pacient moral obvladati določene dejavnosti v nekem določenem časovnem okviru. Smatra se kot osrednja veščina rehabilitacijskih strokovnjakov (1), toda dokazi, da zaradi nje pri pacientih pride do razlik, so omejeni. Nedavni Cochranov pregled postavlj anj a cilj ev v rehabilitacij ski praksi kaže, da obstaja le nekaj slabo kakovostnih dokazov, da določanje ciljev lahko izboljša izide, vendar le pri samoučin-kovitosti ne pa pri telesnem funkcioniranju (2). Postavljanje ciljev zahteva precej časa in naporov (3), zato se postavlja vprašanje ali se jih splača postavljati?
Namen določanja ciljev se razlikuje pri različnih skupinah pacientov in v različnih ustanovah. Izkušeni kliniki se osre-dotočajo na proces razpravljanja in pogajanja, medtem ko se mlajši kliniki osredotočajo na oblikovanje ciljev, da jih ubesedijo po principu SMART (4). To morda kaže na dve različni aktivnosti. SMART določanje ciljev je dobro, toda z njim je nekaj težav. Malo ljudi si postavlja SMART cilje, in če to naredijo, kot na primer ob novem letu, jih pogosto prelomijo. Ljudje uporabljajo SMART cilje na njihovih delovnih mestih. To je uporabno, kadar so cilji specifični, postavljeni soglasno in sprejemljivi, če se smatrajo kot pomoč in kot olajševalec, če so izvajalci dovzetni za ideje, zmožni načrtovanja in če je ocenjevanje izvedbe uvod v nadaljnje postavljanje ciljev, ne pa oceno. Razlika med delom in rehabilitacijo je, da si morajo biti vsi na jasnem o »misiji« njihovega delovnega mesta in cilji so oblikovani tako, da naredijo delo mesto učinkovitejše.
Kaj potem je misija rehabilitacije? Ali je obravnava okvar, izboljšanje dejavnosti in sodelovanja, priprava pacientov na odpust iz bolnišnice ali kaj drugega? Preden rehabilitacijski strokovnjaki določijo cilje, moramo natančneje vedeti zakaj
Summary
Goal setting has been defined as a process of discussion and negotiation in which the patient and staff determine the key priorities for that individual and agree the performance level to be attained by the patient for defined activities within a specified timeframe. It is regarded as a core skill of rehabilitation professionals (1), but the evidence that it makes a difference to patients is limited. A recent Cochrane review of goal setting in rehabilitation practice suggested that there was some very low quality evidence that goal setting may improve some outcomes but this was mainly around attributes such as self efficacy rather than physical function (2). Goal setting takes considerable time and effort (3) which raises the question is it worth while?
The purposes of goal setting vary in different patient groups, and in different settings. Experienced clinicians focus on the process of discussion and negotiation, whereas younger clinicians focus on the articulating the goal in a way that can be seen as SMART (4). This would suggest that these are two different activities. SMART goal setting has captured the imagination, but there are some difficulties with it. Few people set themselves SMART goals, and when they do, such as at New Year, they often break them. People use SMART goals in the work-place, and these can be helpful when the goals are specific, jointly set and reasonable, the manager is regarded as helpful, facilitating, receptive to ideas and able to plan and evaluation of performance is initiated by subordinates and as a prelude to further goal setting, not appraisal. The difference between work and rehabilitation is that everyone should be clear about the 'mission' of their workplace, and the goals are designed to make the workplace more efficient.
What, then, is the mission of rehabilitation? Is it to manage impairment, increase activity and participation, prepare patients for discharge from hospital, or something else? Before rehabilitation professional set goals, we need to be clear about
Poslanono: 4. 1. 2018 Sprejeto: 5. 1. 2018
Naslov za dopisovanje/Corresponding author (DP): D.Playford@warwick.ac.uk
delamo tako, ker bo to vplivalo na to kako cilje določamo in tudi naš pristop k temu.
Priprava pacienta na odpust iz bolnišnice
Ti cilji so pogosto opisani kot »dolgoročni«. Povezani so z datumom odpusta in opisujejo pacientovo predvideno funkcionalno stanje ob datumu odpusta, da se olajša načrtovanje nadaljnje oskrbe ter za sporazumevanje s pacienti in njihovimi bližnjimi o tem, kaj lahko pričakujejo. To so organizacijski cilji in morajo biti napisani v SMART jeziku.
Obravnava okvare
Imamo paciente s hudimi možganskimi okvarami, kot je na primer daljša motnja zavesti, ki ne morejo sodelovati pri določanju ciljev. Za te paciente napišemo akcijske načrte. To so aktivnosti, ki jih mora izvesti multidisciplinarni tim v imenu pacienta, in so lahko napisano tako, da so SMART.
Izboljšanje dejavnosti in sodelovanja
Čeprav ima posameznik lahko krajše obdobje intenzivnejše rehabilitacije, je cilj zagotoviti, da lahko opravlja dejavnosti in sodeluje, čeprav te podpore nima več. To zahteva dva pristopa. Prvi je zagotoviti, da se pacient zaveže ciljem. To je najlažje narediti z uporabo principa deljenega odločanja (5). To je:
•	razvijanje empatije in zaupanja,
•	določanje vrstnega reda in prioritet s pogajanjem,
•	deljenje informacij,
•	sporočanje in obravnava tveganj,
•	podpora,
•	povzemanje in odločanje.
Obstaja nekaj orodij za določanje ciljev, s katerimi omenjeno lahko formaliziramo. Scoobie (6) je uporabil okvir »določanje ciljev - načrtovanje delovanja« (angl. Goal setting - Action planning), v katerem je prepoznal: (i) pogajanje o ciljih, (ii) prepoznavanje ciljev, (iii) načrtovanje ter (iv) oceno in povratno informacijo. Teorija, ki podpira ta model temelji na samoučinkovitosti. Viri samoučinkovitosti so štirje: dokaz možnega obvladovanja, povezane izkušnje, besedno prepričevanje in čustveno stanje. V rehabilitaciji jih lahko podpira doseganje kratkoročnih ciljev, opazovanje pacientov, ki so na rehabilitacijski poti dlje in se izboljšujejo, podpora in spodbujanje terapevtov, sester in zdravnikov ter aktivno obvladovanje tesnobnosti in stresa.
Dolgoročni cilji
Dolgoročno, da se še naprej izboljšuje in vzdržuje dobra kakovost življenja, morajo ljudje z zmanjšanimi zmožnostmi razvij ati samoučinkovitost okoli nj ihove zmanj šane zmožnosti ter dosegati cilje, ki so sorazmerni njihovim vrednotam. V tem smislu se cilji skozi življenje spreminjajo. Skozi cilje realizirajo motive in vrednote višje ravni, ki jih lahko in-
why we are doing so, as this will affect how we set goals and our approach to doing so.
Preparing a patient for discharge from hospital
These goals are often described as 'long term goals', they are associated with a discharge date, and describe the patients anticipated functional status at the date of discharge to facilitate planning their continued care, and to communicate to patients and families what they can expect. These are organisational goals and need to be written in SMART language.
Managing impairment
There are some patients, those with severe brain injury such as a prolonged disorder of consciousness, who are unable to participate in a goal setting process. For these patients, we write action plans. These are activities undertaken by the multidisci-plinary team on behalf of the patient, and they can be written in a way that is SMART.
Increasing activity and participation.
Although an individual may have access to a short a period of intense rehabilitation, the aim is to ensure they can maintain these activity and participation once they are no longer supported. This takes two approaches, first, ensuring that the patient is committed to the goal. This is best done using the principles of shared decision making (5), that is:
•	Developing empathy and trust.
•	Negotiated agenda setting and prioritising.
•	Information sharing.
•	Communicating and managing risk.
•	Supporting deliberating.
•	Summarising and making the decision.
There are few goal setting tools that formalise this. Scobbie (6) used a Goal setting -Actionplanning framework were identified: (i) goal negotiation, (ii) goal identification, (iii) planning, and (iv) appraisal and feedback. In this model the underpinning theory is self efficacy. Four sources of self efficacy are evidence of potential mastery, vicarious experience, verbal persuasion, and emotional state. In a rehabilitation service these can be supported by the achievement of short term goals, watching other patients later on the rehabilitation pathway improve, the support and encouragement of therapists, nurses and doctors, and the active management of anxiety and distress.
Long term outcomes
In the long term, to continue improving and maintain a good quality of life, people with disability need to develop self efficacy around managing their disability and also achieve goals that are commensurate with their values. In this sense goals change throughout life. Higher level motives and values are
tegriramo v hierarhično strukturo (7). Na primer, vrednota »biti dober starš« se lahko odraža kot »preživeti več časa s sinom v dejavnosti, pri kateri uživa«, lahko jo ubesedimo kot cilj »biti sposoben igrati namizne igre« in kot akcijski načrt »vaditi premikanje mojega desnega zgornjega uda z robotskim pripomočkom eno uro vsak dan«. Samo akcijski načrt je SMART in oseba z zmanjšano zmožnostjo bo sodelovala pri tem, če bo videla, kako se povezuje z njenimi vrednotami in če ima neko stopnjo samoučinkovitosti za to nalogo. Spretnost rehabilitacijskih strokovnjakov je zagotoviti, da pacienti zgradijo samoučinkovitost okrog SMART ciljev in da so ti povezani z motivi in vrednotami višjih vrednosti.
realised through goals, which can be integrated in a hierarchical structure (7) So, for example, the value 'being a good parent' may manifest as wanting to 'spend more time with my son doing activities he enjoys', which may be articulated as a goal that is 'being able to play board games', and an action plan which is to 'practice moving my right arm using a robotic aid for an hour each day'. It is only the action plan that is SMART and the person with disability is only likely to engage with this, if they can see how it engages with their values and they have some degree of self efficacy for the task. The skill of the rehabilitation professional is to ensure that patients build self efficacy around SMART goals and that these are related to these values higher level motives and values.
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