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Goal planning in rehabilitation for people with acquired brain injury
Thesis · April 2008
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GOAL PLANNING IN REHABILITATION
FOR PEOPLE WITH ACQUIRED BRAIN
INJURY: A GROUNDED THEORY
INVESTIGATION
William Levack
A thesis submitted for the degree of

Doctor of Philosophy
at the University of Otago, Dunedin,
New Zealand
Date: 7 March 2008

Abstract
Background: Much of the theory around goal planning in rehabilitation has either arisen from
expert opinion or has been directly imported from other fields (such as cognitive psychology
and sport psychology) with limited scientific development of theory specific to rehabilitation
populations. Despite this, goal planning has become a central process in clinical
rehabilitation. Furthermore, many different approaches to goal planning in rehabilitation now
exist, with little robust, scientific evidence to provide guidance regarding which approach is
best, and under which circumstances.
Aim: To use inductive methods to further the development of theory regarding goal planning
in interdisciplinary rehabilitation for people with acquired brain injury.
Methodology: Constructivist grounded theory
Methods: Two empirical studies were undertaken. The first of these involved interviews with
nine clinicians from a range of professional backgrounds, with experience in brain injury
rehabilitation. The aim of this study was to identify how clinicians conceptualised goal
planning and its function in rehabilitation. In the second study, data collection and analysis
centred on a series of cases involving people admitted to hospital with stroke. Data for this
second study were collected from multiple sources including interviews with patients, family
members and clinicians; from audio-recorded observation of assessments, therapy, team
meetings and family meetings; from documentation in clinical files and from field notes taken
during an eight month observation period. Nine patients, seven family members, and 28
clinicians participated in this second study. Data analysis focused on the ways these various
stakeholders interacted with one another around goals and goal planning.
Results: The first study revealed that while the clinicians considered goal planning important,
the expressed reasons for valuing goal planning were at times unclear. The term ‘goal’
referred to not one but many concepts within rehabilitation, and goal planning was used to
serve a range of different purposes. Different reasons for undertaking goal planning were
interrelated but at times conflicted, creating potential for tensions within the rehabilitation
environment. From the second study, a substantive theory was constructed which explained
how, in inpatient rehabilitation for people with stroke, certain goals (characterised by short
ii
timeframes, conservative estimation of outcomes, and an orientation to physical function)
were prioritised or ‘privileged’ over others. Involvement of patients and family members in
goal planning appeared to result in interactional dilemmas for clinicians when the objectives,
attitudes and perceived capacity of patients or families did not align with these privileged
goals. Clinicians attempted to resolve these dilemmas by navigating their way through a
discourse of patient-centred therapy while retaining control of the documented goals of
rehabilitation. As a result, documented team goals appeared to describe rather than drive the
rehabilitation process, compromising the ideals of ‘patient-centred’ rehabilitation.
Conclusion: This thesis provides an explanatory framework for better understanding goal
planning within the context of rehabilitation for brain injury. The results from this thesis can
be used to guide interdisciplinary teams in the development of a shared understanding of goal
planning and as the basis for a future programme of research into goal planning in
rehabilitation.
iii
Publications arising from this thesis
Levack, W. M. M., Dean, S., Siegert, R. J., & McPherson, K. M. (2006). Purposes and
mechanisms of goal planning in rehabilitation: the need for a critical distinction. Disability &
Rehabilitation, 28(12), 741-749.
Levack, W. M. M., Dean, S. G., McPherson, K. M., & Siegert, R. J. (2006). How clinicians
talk about the application of goal planning to rehabilitation for people with brain injury -
variable interpretations of value and purpose. Brain Injury, 20(13-14), 1439-1449.
Levack, W. M. M., Taylor, K., Siegert, R. J., Dean, S. G., McPherson, K. M., & Weatherall,
M. (2006). Is goal planning in rehabilitation effective? A systematic review. Clinical
Rehabilitation, 20(9), 739-755
iv
Conference presentations arising from this thesis
Levack, W. M. M. (2007). Manipulating patient motivation through goal planning: clinical
opinion, psychological theory and the limits of scientific knowledge. Paper presented at the
Physiotherapy Southern Symposium, Queenstown, New Zealand.
Levack, W. M. M., Dean, S. G., McPherson, K. M., & Siegert, R. J. (2007). Goal planning
for people with acquired brain injury: how clinicians talk about involving family. Paper
presented at the National Rehabilitation Research Institute of New Zealand and New Zealand
Rehabilitation Association Conference, Rotorua, New Zealand.
Levack, W. M. M., Dean, S. G., McPherson, K. M., & Siegert, R. J. (2006). How clinicians
talk about the purpose, process and experience of goal planning in interdisciplinary
rehabilitation. Paper presented at the New Zealand Association of Occupational Therapy
Conference.
Levack, W. M. M., Taylor, K., Siegert, R. J., Dean, S. G., McPherson, K. M., & Weatherall,
M. (2005). Is goal planning in rehabilitation effective? A systematic review. Paper presented
at the New Zealand Rehabilitation Association Conference.
Levack, W. M. M. (2005). How clinicians talk about the functions, process and experience of
involving patients in goal setting. Paper presented at the 11th Qualitative Health Research
Conference, Utrecht, the Netherlands.
Siegert, R. J., Levack, W., Dean, S., & McPherson, K. (2005). The whys and wherefores of
goal setting in rehabilitation. Paper presented at the Indian Association for Physical Medicine
and Rehabilitation XXXIII Annual National Conference
v
Acknowledgements
This thesis could not have been completed without the support that was provided by a number
of people. I would firstly like to thank, most sincerely, my supervisors for their ongoing
enthusiasm and commitment: Dr Richard Siegert, Dr Sarah Dean and Professor Kath
McPherson. All have contributed to the development of my work in different and
complementary ways. I have considered myself lucky on many occasions to have had such
tremendous supervision; from people who are such excellent theoreticians themselves, but
who also have excelled in the (at times, difficult) job of assisting me to stay on task. My
supervisors have not only provided me with excellent advice about my PhD studies, but have
also, over the years, been fantastic career mentors. Professor Kath McPherson, in particular,
has been nudging me ever onwards in academia for the past ten years now.
I would also like to thank Kathryn Taylor and Dr Mark Weatherall for their input into the
systematic review described in this thesis. Kathryn dedicatedly read over a thousand abstracts
and hundreds of papers as the second reviewer for this systematic review. Mark’s input was
equally invaluable, in advising on the development of review methodology and in the more
curly aspects of critical appraisal (e.g. evaluation of ‘intention to treat’ and statistical analysis
of block randomisation). Thank you.
My thanks also go to Pat Hartwell, from Central Secretarial Services, and Vanessa Young, for
the very professional assistance they provided, transcribing audio-recordings for the second
grounded theory study in this thesis. I am also indebted to the Wellington Medical Research
Foundation, for a travel grant which enabled me to attend the 11th Qualitative Health
Research Conference in Utrecht, the Netherlands, to present some of my preliminary data.
This thesis could clearly not have been possible without the interest and willingness of the
many research participants and organisations involved. I therefore extend a very warm thank
you to all the patients, family members, hospital managers, nurses, doctors, physiotherapists,
occupational therapists, social workers, speech language therapists, and all the other clinicians
who participated in or supported my studies.
Finally, I would like to offer my wholehearted thanks to my wonderful, tolerant, and loving
family: Jo, my life-long partner and best friend, and our three kids: Zoë, the eternal seeker of
wisdom and knowledge (born on the completion of my Masters thesis, now turned six!), the
vi
effervescent Eva (aged three and half), and our latest acquisition, the blue-eyed and bouncy
Caspar (just on nine months old). During the writing of this thesis, I asked Zoë and Eva what
a ‘goal’ was. Zoë took one look at the digital recorder in my hand and replied: ‘You’re trying
to trick us’, refusing to make any further comment. Eva, as always, followed the lead of her
big sister. Very sensible.
I dedicate this thesis, however, to my parents: Hamish and Glenis Levack. My parents have
always supported and encouraged me in my education, and instilled in me a fascination with
science and a belief in my capabilities. I grew up with a Dad who told endless stories about
ancestors who pursued research and innovation in medicine and engineering (among other
things) and a Mum, who taught me how to do Student t-tests, aged eleven, so I could analyse
data from my slater experiments (Porcellio scaber!); who boiled onions to make acid-base
indicators; and who brought home, on two separate occasions, a cow’s eyeball and a deceased
guinea pig for dissection on the kitchen table. An unusual upbringing perhaps, but lots of fun!
vii
Table of contents
Abstract ............................................................................................................................ ii
Publications arising from this thesis ..................................................................................... iv
Conference presentations arising from this thesis .................................................................. v
Acknowledgements.............................................................................................................. vi
Table of contents................................................................................................................ viii
List of tables ......................................................................................................................... x
List of figures ...................................................................................................................... xi
List of abbreviations ........................................................................................................... xii
Chapter 1: Introduction ......................................................................................................... 1
1.1 Background ......................................................................................................... 1
1.2 Definitions of key concepts.................................................................................. 3
1.3 Research aims...................................................................................................... 7
1.4 Thesis structure ................................................................................................... 8
Chapter 2: Variability in interpretation of goal planning and its function in rehabilitation – a
literature review................................................................................................. 11
2.1 Introduction....................................................................................................... 11
2.2 Origins and interpretations of goal planning in rehabilitation literature .............. 12
2.3 Method .............................................................................................................. 24
2.4 Results............................................................................................................... 26
2.5 Discussion ......................................................................................................... 38
2.6 Conclusion ........................................................................................................ 42
Chapter 3: Effectiveness of goal planning in rehabilitation – a systematic review................ 43
3.1 Introduction....................................................................................................... 43
3.2 Method .............................................................................................................. 46
3.3 Results............................................................................................................... 49
3.4 Discussion ......................................................................................................... 65
3.5 Conclusions....................................................................................................... 67
Chapter 4: Grounded theory ................................................................................................ 68
4.1 Introduction....................................................................................................... 68
4.2 Grounded theory methodology – origins and interpretations .............................. 69
4.3 Justification for the approach taken in this thesis ............................................... 86
viii
4.4 Conclusion ........................................................................................................ 88
Chapter 5: How clinicians talk about the application of goal planning to rehabilitation for
people with acquired brain injury....................................................................... 90
5.1 Introduction....................................................................................................... 90
5.2 Method .............................................................................................................. 96
5.3 Results............................................................................................................... 98
5.4 Discussion ....................................................................................................... 141
5.5 Conclusion ...................................................................................................... 144
Chapter 6: Privileged versus patient-centred goals in inpatient stroke rehabilitation: a
grounded theory investigation.......................................................................... 145
6.1 Introduction..................................................................................................... 145
6.2 Method ............................................................................................................ 147
6.3 Results............................................................................................................. 156
6.4 Discussion ....................................................................................................... 191
6.5 Conclusion ...................................................................................................... 203
Chapter 7: Discussion and conclusions.............................................................................. 204
7.1 Summary of research ....................................................................................... 204
7.2 Implication for goal theory in rehabilitation..................................................... 205
7.3 Limitations of the research and future directions.............................................. 213
7.4 Self-reflection on the research process ............................................................. 215
7.5 Conclusions..................................................................................................... 216
Glossary ........................................................................................................................ 218
References ........................................................................................................................ 225
Appendix 1: Key to transcription conventions................................................................... 235
ix
List of tables
TABLE 1: Characteristics of the content of goals resulting from various approaches to goal
planning in rehabilitation ...................................................................................... 19
TABLE 2: Intended purposes of goal planning in rehabilitation and their hypothesised
mechanisms as described in the current literature.................................................. 27
TABLE 3: Comparison of PEDro scores for included studies................................................. 52
TABLE 4: RCTs on the effect of goal planning on treatment outcomes.................................. 55
TABLE 5: RCTs on the effect of goal planning on treatment adherence in rehabilitation
programmes running for > 1 week ........................................................................ 61
TABLE 6: RCTs on the immediate effect of goal planning on patient behaviour, investigated
over a short period of time (< 3 days) ................................................................... 63
TABLE 7: Purposes of goal setting explicitly identified by the clinicians interviewed.......... 103
TABLE 8: Initial interview schedules .................................................................................. 153
TABLE 9: Characteristics of participating patients in the study............................................ 159
x
List of figures
FIGURE 1: Structure of the thesis........................................................................................ 9
FIGURE 2: Process for inclusion of studies in the systematic review................................. 50
FIGURE 3: Purposes of goal planning in clinical rehabilitation for people with acquired
brain injury ................................................................................................... 105
FIGURE 4: Purposes for patient participation in goal planning ........................................ 108
FIGURE 5: Flowchart documenting entry into the study and data collection.................... 151
xi
List of abbreviations
ACC Accident Compensation Corporation
COPM Canadian Occupational Performance Measure
GAS Goal Attainment Scaling
GMT Goal Management Training
ICF International Classification of Functioning, Disability and Health
IDT Interdisciplinary Team
PEDro Physiotherapy Evidence Database
RCT Randomised Controlled Trial
RLGQ Rivermead Life Goals Questionnaire
SIGA Self-Identified Goals Assessment
The acronyms ‘SMART’ and ‘RUMBA’ are also referred to throughout this thesis.
Note: these are not abbreviations, but acronyms that are sometimes suggested to
remember key components of goal planning promoted by various authors.
Interpretations of these acronyms differ. One interpretation of the ‘SMART’ acronym
is that it stands for specific, measurable, achievable, relevant, and time-limited goals
(Barnes and Ward, 2000). Similarly, ‘RUMBA’ has been said to stand for relevant,
understandable, measurable, behavioural, and achievable (Barnett, 1999). More
information about these acronyms is provided in Chapter 2 of this thesis.
xii
Chapter 1 - Introduction
Chapter 1: Introduction
1.1 Background
This thesis explores the concept of goal planning within the context of interdisciplinary
rehabilitation for people with acquired brain injury. It is proposed in this thesis, that over the
years, goal planning has gained a rather unusual place in clinical rehabilitation, becoming
what many would consider an essential component of the rehabilitation process without any
international consensus regarding what a rehabilitation goal is or the ‘correct’ way to go about
it. Indeed, the literature is filled with many different approaches to goal planning and
multiple perspectives on what might or might not constitute a ‘goal’ in rehabilitation.
As a physiotherapist working in both hospital and community-based rehabilitation for

people with acquired brain injury, I gained first-hand a sense of the challenges associated with
meeting what I had been taught were the ideals of good goal planning practice. Goal
planning, it seemed, involved a significant investment of time for both the individual clinician
and the interdisciplinary team as a whole. Nor was goal planning an exercise for just the
beginning of an episode of rehabilitation: ongoing effort was required to re-evaluate goals, to
discuss them as a team and to set new goals as patients progressed. At what point, I
wondered, were the human resource costs associated with goal planning greater than the
benefits gained? Were some approaches to goal planning more efficient and more effective
than others?
Prior to this thesis I also had completed a Master’s research project in which I
investigated the experiences of people who had attempted to return to work after traumatic
brain injury (Levack, 2002; Levack, McPherson, & McNaughton, 2004). One incidental
finding from this phenomenological investigation was that the people interviewed appeared to
be more interested in the ongoing ‘journey’ of rehabilitation than on achievement of some
pre-specified goals. In fact, a few interview participants expressed frustration, believing that
documented goals were used on occasions to limit their rehabilitation opportunities, with
decisions regarding levels of goal achievement providing justification to discharge them from
rehabilitation services or to cease interventions (Levack, 2002). Again, this raised questions
regarding how goal planning was used in clinical settings and to what ends.
1
In preparation for this PhD thesis, I undertook a preliminary review of the literature.
This revealed a few key issues that further focused the development of my research aims.
Firstly, at the time of my PhD enrolment there appeared to be no existing systematic review
of the research on goal planning in rehabilitation, although a few narrative reviews on the
topic had been published (e.g. Malec, 1999; Wade, 1998, 1999a). Secondly, different
rehabilitation services did indeed appear to use different approaches to goal planning, but with
little evidence-based research to guide the selection of an approach specific to individual
practice (Playford et al., 2000). Thirdly, there appeared to have been a number of unresolved
challenges associated with goal planning in rehabilitation, such as how best to involve
patients with cognitive or communicative impairments, and how clinicians were to make
goals set in hospital environments relevant to people’s lives in the community (Playford et al.,
2000). Fourthly, at the time of my enrolment, my own PhD supervisors were in the midst of
developing an argument that research into goal planning in rehabilitation had developed in a
fairly pragmatic fashion with studies designed to address the question of ‘what works’
without any substantially associated development of theories regarding ‘how’ or ‘why’ goal
planning in rehabilitation might work (Siegert, McPherson, & Taylor, 2004; Siegert & Taylor,
2004). A gap in the literature appeared to exist regarding the construction of theory relating
to goal planning, and in particular to how ‘goals’ and ‘goal planning’ were conceptualised in a
rehabilitation context.
One strategy for the advancement of goal theory in rehabilitation would be to search
further afield, looking for existing theories on goal planning from other disciplines (in
particular the social sciences) that could be tested within rehabilitation settings. Indeed, this
has been an approach argued for by my PhD supervisors with particular reference to theories
from cognitive psychology on the relationship between goals, mood, self-efficacy, and
motivation (Siegert et al., 2004; Siegert & Taylor, 2004). Another strategy (and the one
adopted for this thesis) would be to use qualitative methods in order to construct new
perspectives on goal planning from the clinical environment itself. This alternative strategy is
based on the premise that, as goal planning is already employed in rehabilitation
environments, inductive reasoning could be used to gather information that might
meaningfully inform the development of theory specific to clinical settings. Of course these
two strategies (deductive and inductive approaches to theory development) are not mutually
exclusive. Rather it could be reasonably assumed that they are likely to inform one another.
2
For this thesis, I have used constructivist grounded theory to investigate the application
of goal planning in rehabilitation for people with acquired brain injury. I undertook two
grounded theory studies: the first focused solely on how health professionals talked about the
application of goal planning for people with brain injury, while the second followed a group
of people with stroke through their inpatient rehabilitation, investigating from multiple
perspectives how goal planning was applied to specific clinical cases. As background to these
studies I undertook two critical reviews of the literature: one of which was a structured
analysis of the hypothesised purposes and mechanisms attributed to goal planning in clinical
rehabilitation; the other was a systematic review of randomised controlled trials investigating
the effectiveness of goal planning to improve patient outcomes following rehabilitation. In
order to provide a broad foundation for the empirical studies in this thesis, the scope of these
two library-based investigations included papers on rehabilitation for any acquired disability,
not just for people with brain injury.
Prior to clarifying the specific aims of this thesis, it is necessary to firstly present some
definitions of the key concepts to be considered. As mentioned above however, there are
multiple possible interpretations of the terms ‘goal’ and ‘goal planning’. Indeed, one aspect
of this thesis is to closely examine interpretations such as these. Therefore, from the outset it
is assumed that no single, internationally-agreed definition of either of these terms exists in
literature on clinical rehabilitation. Instead, a range of definitions are provided below, in
order to clarify where possible the intended scope of this thesis. (In addition to these
definitions, a glossary has been provided at the back of this thesis regarding other terminology
used.)
1.2 Definitions of key concepts
1.2.1 Definitions of a ‘goal’
Within the field of psychology there is an enormous body of literature describing and
analysing goal constructs from multiple perspectives (Austin & Vancouver, 1996). With this
breadth of interpretation of the term in mind, Austin and Vancouver (1996) have defined
‘goals’ as ‘internal representations of desired states, where states are broadly construed as
outcomes, events, or processes’ (p. 338). For other authors in the field of psychology
3
however, the term ‘goal’ has referred to a substantially more specific concept. Locke and
Latham (2002) for instance referred to ‘goals’ from the perspective of motivation and human
performance in industrial-organisational settings. Thus, in their definition, they emphasised
measurable levels of performance, stating that a ‘goal’ is ‘the object or aim of an action, for
example, to attain a specific standard of proficiency, usually within a specified time limit’
(Lock and Latham, 2002, p. 705).
In rehabilitation literature, the concept of a ‘goal’ tends to be placed within the context
of clinical work. For example, Wade defined a goal as:
A future state that is desired and/or expected. The state might refer to relative
changes or to an absolute achievement. It might refer to matters affecting the
patient, the patient’s environment, the family or any other party. It is a generic
term with no implications about time frame or level (Wade, 1998, p. 273).
Likewise, Randall and McEwen defined a ‘functional goal’ within the context of
physiotherapy as:
…the individually meaningful activities that a person cannot perform as a result of

an injury, illness, or congenital or acquired condition, but wants to be able to
accomplish as a result of physical therapy (Randall & McEwen, 2000, p. 1198).
1.2.2 Defining ‘goal setting’ and ‘goal planning’
‘Goal planning’ or ‘goal setting’ is an activity related to establishing or having ‘goals’.

In clinical rehabilitation, Wade (1998) has defined the terms ‘goal setting’ and ‘goal planning’
(which he considered synonymous) as: ‘The process of agreeing on goals, this agreement
usually being between the patient and all other interested parties’ (p. 273). Similarly,
Playford et al. (2000) have suggested that goal setting is: ‘The process of agreeing on a
desirable and achievable future state’ (p. 491). Of note here, the concept of ‘goal planning’ in
rehabilitation usually appears to refer to a relationship between an individual patient and an
individual or group of health professionals (and/or others). This excludes goals set at an
organisational level (e.g. in the case of health service management) or community level (e.g.
in the case of public health policy) from the definition of ‘goal planning’ or ‘goal setting’ in a
rehabilitation context. In other words, while goals such as ‘to reduce the incidence of falls in
hospital’ may be an important key performance indicator for a particular rehabilitation
4
service, these types of organisational goals are not what is usually being discussed in
literature on goal planning in rehabilitation.
Interestingly, in the field of psychology, definitions of goal setting do not always

include the selection of the topic of the goal. In Locke and Latham’s (2002) goal theory, for
instance, the process of goal setting has been described in terms of the conscious selection of
the level of task performance rather than any decision regarding what task to pursue per se.
To provide an example relevant to rehabilitation, this definition of ‘goal setting’ would
perhaps include the selection of the speed with which a walking task might be completed
rather than the choice of ‘independent walking’ as the topic of the goal.
1.2.3 Defining ‘rehabilitation’
In addition to definitions for ‘goals’ and ‘goal planning’, it is important for the purposes
of this thesis to define the term ‘rehabilitation’. While again multiple interpretations of the
term ‘rehabilitation’ exist, for the purposes of this thesis the following definition provided by
the World Health Organisation will be used:
The term ‘rehabilitation’ refers to a process aimed at enabling persons with

disabilities to reach and maintain their optimum physical, sensory, intellectual,
psychiatric and/or social functional levels, thus providing them with the tools to
change their lives towards a higher level of independence. Rehabilitation may
include measures to provide and/or restore functions, or compensate for the loss or
absence of a function or for a functional limitation. It includes a wide range of
measures and activities from more basic and general rehabilitation to goal-oriented
activities, for instance vocational rehabilitation. The rehabilitation process does
not, however, involve initial medical care. (World Health Organization, 2001b, p.
290)
1.2.4 Defining ‘interdisciplinary team’
Throughout this thesis, I use the term ‘interdisciplinary team’ (IDT) to refer to the type
of team under investigation (with respect to goal planning). The term ‘interdisciplinary’
refers to one of three models of teamwork presented in the literature on rehabilitation, the
other two being multidisciplinary and transdisciplinary (Nair & Wade, 2003; Opie, 2000;
Suddick & De Souza, 2006). Once again, these are all difficult terms to use in research
5
because of a lack of shared terminology or criteria surrounding them (Suddick & De Souza,
2006). However, for the purpose of this thesis, I have chosen to use the term IDT, as defined
by Opie (2000):
An interdisciplinary team is characterized by joint activity, collaboration, the

beginnings of shared linguistic practices, and shared responsibility (Sands, 1993).
The outcome is accomplished by interactive work, contributions requiring
attention to team process (Bailey, 1984), and the development of an action
consensus as a way of focusing on task and maintaining group activity. (Opie,
2000, p39-40)
According to Opie (2000), interdisciplinary teamwork differs from multidisciplinary

teamwork because, in the latter, team members work in parallel, each operating independently
of one another, with infrequent meetings and limited collaboration. Transdisciplinary
teamwork, on the other hand, is seen to be characterised by ‘integrated thinking based on the
sharing of knowledge and greater blurring of professional boundaries than in an
interdisciplinary team’ (Opie, 2000, p40). Arguably, the clinicians who participated in the
studies described in this thesis might have chosen to refer differently to the structure of their
team: perhaps as a multidisciplinary or transdisciplinary team. It is not necessarily easy to
even identify the dominate model of teamwork in everyday practice for any rehabilitation
team (Opie, 2000; Suddick & De Souza, 2006). However, for the purposes of clarity, and on
the basis of the definition provided by Opie (2000) above, the term IDT will be used hereon
in.
1.2.5 Defining ‘acquired brain injury’
Finally, as mentioned above, the empirical research in this thesis centres on

rehabilitation for people with acquired brain injury. ‘Acquired brain injury’ has been defined
as: ‘an injury to the brain, commonly caused by trauma, stroke, hypoxia or infection, that
results in a deterioration in cognitive, physical or emotional function which may be temporary
or permanent’ (Harris, Nagy, & Vardaxis, 2006, p. 21).
The research in this thesis however is focused specifically on two conditions that fall
within this definition: traumatic brain injury and stroke. ‘Traumatic brain injury’ has been
described as ‘injury resulting from trauma to the head and its direct consequences including
6
hypoxia, hypotension, intracranial haemorrhage and raised intracranial pressure’ (Turner-

Stokes, Disler, Nair, & Wade, 2005, p. 2). Traumatic brain injury specifically excludes pre-
and peri-natal brain damage secondary to prenatal and birth-related events (New Zealand
Guidelines Group, 2006).
The term ‘stroke’ (also referred to as a ‘cerebrovascular accident’) has been defined as
‘an abnormal condition of the brain, characterised by occlusion by an embolus, thrombus, or
cerebrovascular haemorrhage or vasospasm, resulting in ischemia of the brain tissues
normally perfused by the damaged vessels’ (Harris et al., 2006, p. 330).
1.3 Research aims

The main objective of this thesis is to use inductive methods to further the development
of theory regarding goal planning in interdisciplinary rehabilitation for people with acquired
brain injury. To this end, there are two aims underpinning the empirical studies in this thesis:
1. To use grounded theory to explore how clinicians talk about the application of goal
planning in rehabilitation for people with acquired brain injury, and
2. To use grounded theory to explore how goal planning is applied in interdisciplinary

rehabilitation settings for people with acquired brain injury, and how goals and goal
planning are conceptualised by the various stakeholders (e.g. clinicians, patients and their
family/whānau) involved.
In addition to these aims, and as a precursor to the empirical studies, this thesis also
seeks to investigate the representation and conceptualisation of goal planning in the current
literature on clinical rehabilitation. This background work is driven by two further aims:
3. To examine how goal planning is conceptualised in the literature on clinical

rehabilitation, in terms of its hypothesised purposes (why goal planning is considered
important) and mechanisms (how goal planning is believed to achieve its desired effects),
and
7
4. To examine the current best evidence regarding the effectiveness of ‘goal planning’ to
improve patient outcomes following rehabilitation.
1.4 Thesis structure

As described above, this thesis consists of two library-based investigations and two
empirical studies into the application of goal planning in rehabilitation. Figure 1 provides an
overview of the thesis structure. The two library-based investigations, presented in Chapters
2 and 3, offer different perspectives on the current literature and should be considered in
tandem. Chapter 2 begins with a brief historical perspective on the origins and interpretation
of goal planning in rehabilitation before presenting the methods and results from a structured
review of the literature investigating the hypothesised purposes and mechanisms attributed to
goal planning in clinical contexts. The preliminary typology of purposes and mechanisms
from Chapter 2 also provides a foundation for the work in Chapter 3: a systematic review of
the literature examining the best available evidence regarding the effectiveness of goal
planning in rehabilitation to positively influence patient outcomes as determined by
standardised outcome measures.
Chapter 4 introduces grounded theory – the methodology employed in the two

qualitative studies in this thesis. This chapter includes a background to ground theory and
describes the epistemology, theoretical perspectives and methodological assumptions
necessary for its application. A justification is provided for the selection of constructivist
grounded theory as the approach taken to the qualitative studies in this thesis.
Chapter 5 presents a grounded theory investigation of how health professionals talk

about the application of goal planning in interdisciplinary rehabilitation for people with
acquired brain injury. The results from this study focus on the values attributed to goal
planning and the reasons or purposes underpinning the clinicians’ use of goal planning in
clinical settings. Tensions arising from competing purposes for goal planning are discussed
and related to challenges that clinicians report experiencing when applying goal planning in
clinical rehabilitation for people with brain injury. Complexities regarding the
conceptualisation of goal planning in clinical settings are also explored.
8
FIGURE 1: Structure of the thesis
Library-based Studies
Chapter 2: Analysis of the Chapter 3: Systematic review of the

hypothesised purpose and literature on the effectiveness of
mechanisms attributed to goal goal planning to improve patient
planning in rehabilitation outcomes following rehabilitation
Chapter 4: Grounded theory

methods and methodology
Empirical Studies

exploration of how clinicians talk
about the application of goal
planning to rehabilitation for
acquired brain injury

exploration of the application of
goal planning in rehabilitation for
people with stroke
Chapter 7: Discussion and

conclusions
9
Chapter 6 builds on this work, using grounded theory to explore the application of goal
planning in a series of cases involving people receiving inpatient rehabilitation following a
stroke. Where the study in Chapter 5 analyses how rehabilitation professionals talk in general
about goal planning, this study focuses on goal planning within the context of specific cases.
In order to explore the concepts of goals and goal planning in rehabilitation in more depth,
data for this second qualitative study were collected from multiple sources including
interviews with patients, family members and clinicians; from audio-recorded observation of
interactions between patient, family members and clinicians during assessments, therapy,
team meetings and family meetings; from documentation in the patient files and from field
notes taken during an eight month observation period. Patients and family members were
also followed up three to four months after their discharge from inpatient rehabilitation for an
interview where they reflected on their experiences. This research is used to construct a
substantive theory to explain the ways various stakeholders involved in individual cases
interact with one another around goals and goal planning. In particular, this study examines
the concept of ‘patient-centred’ goal planning and explores how clinicians navigate around
this concept in their interactions with patients and family members, while retaining interests
in certain types of goals that they privileged over others.
The results from all of these studies and literature reviews are discussed in Chapter 7.
This discussion returns to the original aims of the thesis: to explore how inductive analysis of
data from clinical experiences and clinical settings could be used to advance the development
of theory regarding goal planning in rehabilitation. General reflections on the limitations of
the research are presented and suggestions are made regarding future research that is required
in order to further progress knowledge in this area of clinical practice.
10
Chapter 2: Variability in interpretation of goal planning and its function
Chapter 2: Variability in interpretation of goal planning and its

function in rehabilitation – a literature review
2.1 Introduction
This chapter explores the variability in interpretation of goal planning in the literature
on clinical rehabilitation: interpretation of what it is, what it does and how it does it. To begin
with, goal planning in rehabilitation is considered from a historical perspective, looking at the
origins and development of the concepts ‘goals’, ‘goal planning’, and ‘goal setting’ in
rehabilitation contexts. A number of published approaches to goal planning in rehabilitation
are identified and examined for variability with regard to a range of factors: the professional
group (or groups) intended to use a particular approach, the intended patient populations for
various approaches, the process by which goals are selected, the recommended characteristics
of the goals set, the recommended content of goals set, and the way the goals are subsequently
used in clinical settings.
Following this historical overview, a method is presented for a more structured review,
which was conducted in order to extract a clearer understanding of the different functions
attributed to goal planning in rehabilitation literature. The result of this review was a
preliminary typology of purposes to which goal planning has been applied, and mechanisms
(or modes of action) by which goal planning has been thought to effect change upon the
variables of interest. It is argued in this chapter that despite the ubiquitous language
surrounding goals and goal planning, the process itself appears variable and directed at
several different purposes in rehabilitation. For example, Evans and Hardy (2002) reported a
study in which goal planning was used to enhance treatment adherence and patients’ feelings
of self-efficacy. In contrast to this, Wressle, Eeg-Olofsson, Marcusson, and Henriksson
(2002) investigated using goal planning primarily as a means of enhancing patient autonomy.
In other words, the function of goal planning may well vary in rehabilitation settings and
rehabilitation research. Before answering other questions, such as how effective goal
planning might be in rehabilitation, there is a need to identify and specify the different
purposes that goal planning could serve. It may even be possible that goal planning might
work well for one purpose in one rehabilitation setting and not for another. It is important
from the outset to establish that this chapter does not attempt to critically review the evidence
11
regarding the effectiveness of goal planning to achieve these purposes – that work is
presented in Chapter 3. Rather, it is argued here, that before any evaluation of research into
the effectiveness of goal planning in rehabilitation can be attempted, it is firstly necessary to
clarify the qualitatively different reasons for pursuing goal planning.
The work completed for this chapter also provides a framework for gaining greater
sensitivity to data related to goal planning in rehabilitation. It is thus relevant to inductive
research exploring the perspectives of health professionals on goal planning in rehabilitation
(cf. Chapter 5) and to investigation of the application of goal planning in clinical settings (cf.
Chapter 6).
2.2 Origins and interpretations of goal planning in rehabilitation literature

Goal planning is considered a fundamental component of contemporary rehabilitation.
It has been variously described as ‘the essence of rehabilitation’ (Barnes & Ward, 2000, p.8),
‘the cornerstone of effective rehabilitation’ (Lawler, Dowswell, Hearn, Forster, & Young,
1999, p. 402), ‘one of the skills that most specifically characterises professionals involved in
rehabilitation’ (Wade, 1998, p. 273) and ‘a prerequisite for interdisciplinary teamwork’ (Schut
& Stam, 1994, p 223). In clinical practice there has been growing emphasis on the need for
interventions with patients to be goal-oriented with goal terminology becoming integral to
discussions of guidelines, policies and professional requirements at both regional and
international levels (Accident Compensation Corporation & National Health Committee,
1998; Baskett, 1996; Duncan et al., 2005; Evans, Zinkin, Harpham, & Chaudury, 2001; New
Zealand Guidelines Group, 2006; Randall & McEwen, 2000; Rothstein, Echternach, &
Riddle, 2003; Royal College of Physicians and British Society of Rehabilitation Medicine,
2003; Royal College of Physicians of London, 2004). Goal planning has been presented by
some as more than just an adjunct to clinical practice, with claims that somehow goals are
‘central to the process of rehabilitation’ (Wressle et al., 2002, p. 5). Goal planning has been
linked to a conceptualisation of rehabilitation as a purposeful problem solving activity, with
analogies drawn between goal planning in rehabilitation and machine models of human
problem solving from experimental psychology (McGrath & Davis, 1992).
12
Goal planning did not always have this high profile in the practice of rehabilitation
however. The origins of contemporary rehabilitation in the Western World can be dated back
to the early 1900s (if not before), with the growth of a collective sense of social obligation to
address the needs of war veterans, injured workers, and children with disabilities, particularly
with regard to their economic productivity and independence (Kessler, 1965; Swan, 1964). In
comparison, the process of ‘goal planning’ or ‘goal setting’ did not appear to gain prominence
in the literature on rehabilitation until the late 1960’s. One of the earliest and most influential
references to a structured approach for goal planning was a paper by Kiresuk and Sherman in
1968, which described the development of Goal Attainment Scaling (GAS) for mental health
services (Kiresuk & Sherman, 1968). Within ten years this tool had been applied to over 90
studies, and not just within mental health rehabilitation – although its popularity was
associated with ‘several modifications in and deviations from the original Kiresuk and
Sherman GAS model’ (Cytrynbaum, Ginath, Birdwell, & Brandt, 1979, p. 34).
Despite its popularity, GAS did not completely dominate the rehabilitation literature
and commentaries on other approaches to goal planning in clinical rehabilitation began to
appear. In nursing literature through the late 1960’s and early 1970’s, several authors began
linking the establishment and documentation of individualised patient goals to nurse care
plans (Cross & Parsons, 1971; Little & Carnevali, 1967; Sutaria, 1975; Wagner, 1969;
Zimmerman & Gohrka, 1970). Around this time, nursing literature was beginning to make a
distinction between identifying the objectives (or ‘goals’) of interventions and the tasks
required to achieve those objectives (Sutaria, 1975; Wagner, 1969; Zimmerman & Gohrka,
1970). These publications however were not specific to clinical rehabilitation, and were
instead presented as approaches relevant to all areas of nursing practice.
The development of clinical rehabilitation during the 1970s was associated with a
growing concern regarding the participation of patients in clinical decision making.
Advocacy for the involvement of patients in goal selection, which was not apparent in earlier
publications, including Kiresuk and Sherman’s (1968) paper on the GAS approach, began to
emerge. For example, by the mid-1970’s, Becker, Abrams and Onder (1974) had suggested
that processes for enhancing patient participation in goal setting might improve adherence to
treatment regimes, while Trieschmann (1974) linked patient participation in goal planning to
13
ethical obligations such as working towards outcomes that were individually meaningful and
valued by patients.
Other academics during the 1970s were beginning to empirically test some of the
hypotheses regarding the benefits of goal planning in clinical practice. Cross and Parson
(1971) conducted a small randomised controlled trial (RCT) testing the hypothesis that
patients directed towards meeting goals related to selection of healthy foods from hospital
menus would show greater change in clinically-desired dietary behaviour when compared to
patients who were provided with just education or those provided with no additional
intervention. This study however concluded that while patient education had a statistically
significant effect on adherence to clinically recommended dietary behaviour (at least in the
short term), the addition of pre-specified goals regarding daily food choices provided no
further clinical benefit (Cross & Parsons, 1971). Later in the 1970s, LaFerriere and Calsyn
(1978) and Hart (1978) had more success demonstrating a link between goal planning and
improvements in patient outcomes in populations of people with mental health disabilities.
Both groups of authors used RCT methods to test the application of modified approaches to
GAS, which involved patient participation in the selection and monitoring of goals (Hart,
1978; LaFerriere & Calsyn, 1978). Hart (1978) reported that regular discussion with patients
on progress towards individualised goals resulted in statistically significant improvements in
goal achievement when compared to a control group receiving similar interventions, similar
involvement in initial goal selection, but no further involvement in monitoring or evaluation
of goal attainment. LaFarriere and Calsyn’s (1978) study concluded that when compared to a
group of control patients who received no structured goal planning, people with mental health
disabilities participating in GAS as part of their therapy had more positive outcomes in terms
of standardised measures of anxiety, self-esteem, and depression. In their paper, LaFerriere
and Calsyn (1978) began to cautiously speculate about the relationship between collaborative
approaches to goal planning in clinical settings and motivation to change, suggesting that this
motivation may arise from clients having ‘an opportunity to determine the direction of
therapy’ (p. 280).
Despite the foundation provided by publications such as those described above, by the
end of the 1970’s goal planning was still considered a relatively new concept in rehabilitation.
For example, in 1978 Gaines noted that while goal-oriented treatment plans were increasingly
14
emphasised within state and federal guidelines for occupational therapy in the United States,
“the requisite skills (had) only recently been included in occupational therapy curricula”
(Gaines, 1978, p. 512). Similarly, textbooks on clinical rehabilitation often omitted
mentioning goal planning at all. For example, Howard Rusk, who has been called by some
the ‘father of rehabilitation medicine’ (Kottke & Knapp, 1988, p. 4), published the fourth
edition of his textbook on clinical rehabilitation in 1977, but in it did not mention any
structured approach to integrating the assessment or setting of goals into therapeutic activities,
let alone the need for such considerations (Rusk, 1977).
From the 1980s onwards however, ‘goal planning’ or ‘goal setting’ started becoming an
increasingly popular component of rehabilitation programmes. In fact, trends in the literature
on goal planning during this period become difficult to determine because of the sheer extent
of publications on the topic. However, by 1999, a postal survey conducted on behalf of the
British Society for Rehabilitation Medicine identified that the majority of rehabilitation
services in the United Kingdom included goal planning in their team processes on a routine
basis, and that patients and their family/carers were actively involved in the goal-setting
process ‘wherever possible’ (Turner-Stokes, Williams, Abraham, & Duckett, 2000, p. 473-
474). Furthermore, through mid-1990s to the current day there has been a proliferation of
papers advocating new or repackaged approaches to goal planning. Today, when considering
how to undertake goal planning in rehabilitation, clinicians can select from a wide range of
potential approaches:
• GAS (Kiresuk & Sherman, 1968),

• Canadian Occupational Performance Measure (COPM) (Pendleton & Schultz-Krohn,
2005; Phipps & Richardson, 2007; Trombly, Radomski, Trexel, & Burnet-Smith,
2002; Wressle et al., 2002; Wressle, Lindstrand, Neher, Marcusson, & Henriksson,
2003),
• ‘SMART’ goal planning (Barnes & Ward, 2000; Mastos, 2007; McLellan, 1997;
Monaghan, Channell, McDowell, & Sharma, 2005; Schut & Stam, 1994),
• ‘RUMBA’ goal planning (Barnett, 1999),
• Self-Identified Goal Assessment (SIGA) (Melville, Baltic, Bettcher, & Nelson, 2002)
• Goal Management Training (GMT) (Levine et al., 2000),
15
• The Rivermead Life Goals Questionnaire (RLGQ) and approaches to goal planning
from Rivermead Rehabilitation Centre (McGrath & Davis, 1992; McGrath, Marks, &
Davis, 1995; Nair, 2003; Wade, 1999a),
• Approaches to goal planning from the Wolfson Neurorehabilitation Centre (McMillan
& Sparkes, 1999)
• Contractually organised goal setting (Powell, Heslin, & Greenwood, 2002)
• Collaborative Goal Technology (Clarke, Oades, Crowe, & Deane, 2006)
• Progressive Goal Attainment Programme (Sullivan, Adams, Rhodenizer, & Stanish,
2006), and
• Patient-centred functional goal planning (Randall & McEwen, 2000).
Approaches to goal planning from industrial-organisational psychology, in particular Locke

and Latham’s (2002) ‘goal theory’, also began to influence rehabilitation for neurological
conditions (Gauggel & Hoop, 2004) and sport injuries (Evans & Hardy, 2002; Theodorakis,
Beneca, Malliou, & Goudas, 1997; Theodorakis, Malliou, Papaioannou, Beneca, &
Filactakidou, 1996).
While these different approaches to goal planning frequently include a number of

common features, such as the need for goals to be measurable or the need for patients to be
involved in goal selection, few such features are universal to all recommended approaches.
Goals arising from the COPM for example do not necessarily need to be measurable because
outcomes are evaluated by patients self-rating their own performance and satisfaction with
respect to their goals on a separate 10-point scale (Law et al., 1991). In a similar vein, a
patient’s ‘life goals’ identified through use of the RLGQ do not need to be measurable
because they are used to provide direction for clinical decision making rather than as a point
of reference for outcome evaluation (Nair, 2003).
Indeed, all approaches to goal planning in rehabilitation differ from one another across a
number of variables. These variables include: the professional group (or groups) intended to
use the approach, the intended patient population for the approach, the process by which goals
are selected, the recommended characteristics of the actual goals set, the recommended
content of goals set, and the way the goals are subsequently used in the clinical setting. Some
of the currently published approaches to goal planning for instance are intended for use in an
16
‘interdisciplinary’ context (Barnes & Ward, 2000; McMillan & Sparkes, 1999; Schut & Stam,
1994; Wade, 1999a), while others are presented in profession-specific contexts.
The COPM (Carswell et al., 2004) and the SIGA (Melville et al., 2002) have been
designed for use by occupational therapists. The COPM in particular was developed initially
as a measurement tool, to assist occupational therapists with implementation of the Canadian
Model of Occupational Performance in their clinical practice (Carswell et al., 2004), and later
described as an approach to goal planning (Pendleton & Schultz-Krohn, 2005; Phipps &
Richardson, 2007; Trombly et al., 2002). The emphasis on occupational therapy is reflected in
the recommended content of goals resulting from the COPM, with a requirement that goals fit
within specific occupational domains (in particular, self-care, productivity, and leisure).
Instructions regarding the use of the COPM discourage the selection of goals that relate solely
to impairments of body structure or body function (Law et al., 2005). Similarly, Randall and
McEwen (2000) describe an approach to goal planning tailored specifically for use by
physiotherapists.
In terms of patient populations, the GMT approach to goal planning has been designed
for use with people rehabilitating from brain injury (Levine et al., 2000). The aim of GMT is
to teach people with brain injury to compensate for disorganised behaviour resulting from
goal neglect, (a cognitive impairment associated with frontal lobe damage). GMT therefore
focuses mainly on problems with executive functioning (Levine et al., 2000). Bergquist and
Jacket (1993) also described an approach to goal planning that addresses the perceived needs
of people with traumatic brain injury. Their approach however, focused on assisting patients
with brain injury to acknowledge and address impaired self-awareness (Bergquist & Jacket,
1993). Other published papers have described goal planning approaches that have been
tailored for different populations of people: for example, those with stroke (Wade, 1999a),
spinal injury (Kennedy, Walker, & White, 1991), and mental health illnesses (Clarke et al.,
2006; MacPherson, Jerrom, Lott, & Ryce, 1999).
There is also considerable variation across recommended approaches to goal planning in

terms of the process by which goals are set. For example, for approaches that claim to
emphasise ‘patient-centred’ goal planning, such as the COPM and SIGA, patient involvement
in goal selection is considered an integral part (Carswell et al., 2004; Melville et al., 2002). In
the case of the COPM, this is taken to the extent that some proponents argue against pursuing
17
therapy in circumstances where patients are unable to identify any ‘occupational performance
issues’ for themselves (Law et al., 2004). For other approaches, patient involvement in goal
selection may be considered desirable but not necessarily essential (Conneeley, 2004;
MacPherson et al., 1999; Randall & McEwen, 2000; Rockwood, Joyce, & Stolee, 1997;
Wade, 1999b), and alternatives (such as family involvement in goal selection) may be
recommended in circumstances where patients are unable to independently participate in the
goal selection process (Law et al., 2005; Randall & McEwen, 2000; Wade, 1999b). For
approaches to goal planning that centre on enhancing teamwork, greater levels of consultation
with multiple parties are often advised, with formal meetings to coordinate information and
perspectives from the various health professionals, family members and other stakeholders
involved (McGrath et al., 1995; McMillan & Sparkes, 1999; Wade, 1999a). In contrast to this
there is some suggestion that for particular types of goal planning in particular contexts,
having an authority figure (e.g. a health professional) select a goal on behalf of a third-party
(e.g. a patient) can have positive effects in terms of that person’s effort and attention resulting
in higher levels of performance on selected tasks (Gauggel & Hoop, 2004).
In addition to differences in the process of goal planning, experts in the field also
diverge over the recommended characteristics of goals selected for use in clinical settings.
Different authors emphasise different features when describing what might constitute a ‘good’
goal. The GAS approach requires stated goals to be objective so that a third party (a health
professional) can judge whether the patient has reached a pre-specified level of goal
achievement (Donnelly & Carswell, 2002; Malec, 1999; Rockwood, Joyce, & Stolee, 1997).
As mentioned above, such operationalisation of the goal itself is not required in the COPM
because patients self-rate their outcomes on a separate 10-point scale (Law et al., 2005).
Other recommended characteristics of goals, according to various authors, include (but are not
limited to) the following: that goals are specific, realistic or achievable, relevant to the patient,
motivating, challenging or difficult, written in language understood by the patient, time-
limited or time-specific, and/or broken down into short and long terms goals. Table 1
provides a broad illustration of some of the variation that has occurred in the emphasis that
different authors have placed on the recommended characteristics of rehabilitation goals.
This table is not intended as a complete overview of the subject but as a way of demonstrating
the range of alternative perspectives on what could be considered ‘ideal’ goals for patients
involved in clinical rehabilitation.
18
TABLE 1: Characteristics of the content of goals resulting from various approaches to goal planning in rehabilitation
goals
Short and long term
Specific or explicit
measurable
Objective or
or realistic
Achievable, attainable,
Relevant to the patient

Motivating*
Challenging / difficult
language (Jargon-free)
Written in lay
goal)
staff and tasks for each
Coordinated (assigned
completion of therapy
Maintainable after
specific
Time-limited or time-
Authors Name of Domains of goals
Approach
Kiresuk & GAS Goal assigned with numerical values

Sherman related to expected outcomes.
(1968)
Malec (1999) GAS Goals need to be put in ‘behavioural’
terms. Goals assigned with numerical
values related to expected outcomes.
Levin et al. GMT Content or domains of goals not

(2000) specified
Wressle et al. Goals arising Three occupational domains: self-care,

(2002) from the COPM productivity, leisure
Gauggel & Locke and Domains of goals not specified
Hoop (2004) Latham’s ‘Goal
theory’
Randall & Not named Goals need to be related to activities
McEwen
(2000)
CONTINUED OVER
19
goals
Short and long term
Specific or explicit
measurable
Objective or
or realistic
Achievable, attainable,
Relevant to the patient

Motivating*
Challenging / difficult
language (Jargon-free)
Written in lay
goal)
staff and tasks for each
Coordinated (assigned
completion of therapy
Maintainable after
specific
Time-limited or time-
Authors Name of Domains of goals
Approach
Bergquist & Not named Domains of goals not specified

Jacket (1993)
Smith (1999) Not named Domains of goals not specified

Melville et SIGA Goals need to be related to activities

al. (2002)
Barnes & ‘SMART’ Domains of goals not specified

Ward (2000)
McLellan ‘SMART’ Goals need to be related to activities

(1997)
Schut & ‘SMART’ & Goals need to be put in ‘behavioural’

Stam (1994) ‘RUMBA’ terms
McMillan & The Wolfson Goals need to be put in ‘behavioural’
Sparks Neurorehabilitat terms. Long term goals should relate to

(1999) ion Centre activities or participation
approach
* This column relates to papers that recommend the content of written goals be ‘motivating’, but which do not further operationalise this term
20
It is interesting to note that even within specific, named approaches to goal planning,
there can be lack of agreement regarding the key features of what should constitute a ‘good’
rehabilitation goal. For example, while the ‘SMART’ approach to goal planning is commonly
promoted in the rehabilitation literature (Barnes & Ward, 2000; Mastos, Miller, Eliasson, &
Imms, 2007; McLellan, 1997; Monaghan, Channell, McDowell, & Sharma, 2005; Schut &
Stam, 1994), there appears to be a number of interpretations about what this acronym means.
Schut and Stam (1994) have stated that the ‘SMART’ acronym refers to goals that are
specific, motivating, attainable, rational, and timed (Schut & Stam, 1994). Alternatively,
McLellan (1997) used this acronym to emphasise that goals should be specific, measurable,
activity-related, realistic, and time-specific, while Barnes and Ward (2000) preferred specific,
measurable, achievable, relevant, and time-limited. Monaghan et al. (2005) reported again a
slightly different combination of words in their interpretation of the SMART acronym.
Rubin (2002) suggested that the ‘SMART’ approach to goal planning originated as a
way of quickly communicating decades of research from industrial-organisation psychology,
but that over time, as people attempted to fit ‘SMART’ goals into different contexts, the
acronym drifted away from its original meaning and from the research on which it was based.
This may explain in part the differences in the recommended qualities of goals resulting from
the ‘SMART’ approach: these various interpretations may be based more on clinical opinion
rather than empirical data.
Similarly, there is a fair degree of variation in terms of the application of GAS in health
care settings. In the original paper by Kiresuk and Sherman (1968), the GAS approach
involved a health professional (who was independent from the person providing the
rehabilitation) selecting one or more goals for therapy, and, for each goal, describing an
ordinal scale of five favourable to unfavourable outcomes. The mid-point on this scale of
possible outcomes was set as the most expected outcome of treatment and given the score ‘0’,
with the scores ‘+2’ and ‘+1’ being assigned to potential outcomes that were better than
expected and ‘-2’ and ‘-1’ being assigned to those that were worse than expected (Kiresuk &
Sherman, 1968). In Kiresuk and Sherman’s (1968) approach, re-evaluation of GAS scores
was also conducted by a third party, independent of the persons providing or receiving the
rehabilitation service (Donnelly & Carswell, 2002; Kiresuk & Sherman, 1968). Variation in
the application of this approach however have included involvement of the patient in the
21
selection of goals (Cytrynbaum et al., 1979; LaFerriere & Calsyn, 1978; Malec, 1999),
involvement of the treating therapist in the selection and/or re-evaluation of goals
(Cytrynbaum et al., 1979; Willer & Miller, 1976), and use of less than five levels for the goal
outcomes (LaFerriere & Calsyn, 1978; Willer & Miller, 1976).
Before leaving the topic of variations in approaches to goal planning, one further aspect
worth exploring is the recommended content (or subject) of goals resulting from each
approach. While some authors place no restrictions on the preferred subject of rehabilitation
goals (e.g. in Barnes and Ward’s, 2000, interpretation of the ‘SMART’ approach; or in
Kiresuk and Sherman, 1968, original GAS method), others are quite explicit about what
rehabilitation goals should be about. Randall and McEwen (2000) for instance recommended
that all goals set by physiotherapists focus on what they call ‘functional limitations and
disabilities that are individually meaningful to patients’ (p. 1198), specifically excluding
impairments of body structure and body function from being the ‘measured goals of therapy’
(p. 1198). Similarly, as mentioned above, the COPM requires the content of goals to be on
topics relating to specific occupational domains: self-care, productivity, and leisure (Law et
al., 1991; Law et al., 2005).
In an attempt to provide a framework for analysis of goal planning for people receiving
community-based rehabilitation after acquired brain injury, Kuipers and collegues developed
a ‘taxonomy’ of goal content (Kuipers, Foster, Carlson, & Moy, 2003). This taxonomy was
derived from a retrospective, qualitative analysis of goal statements in clinical notes and
focused on categorising goals in terms of the aspects of a patient’s life or disability that were
targeted. The taxonomy was divided into five domains: 1) me and my body, 2) looking after
myself, 3) addressing psychosocial issues, 4) relating to others, and 5) services and
information (Kuipers et al., 2003). Each domain was divided into further categories, with
multiple descriptors associated with each category. For example, the domain ‘me and my
body’ had three categories, one of which was ‘personal care’, under which there were five
descriptors: ‘diet/nutrition’, ‘sleep’, ‘self-care’, ‘hygiene’, and ‘medication’(Kuipers et al.,
2003).
The reliability of this taxonomy was supported by a second study, which investigated its
application to a separate sample of people with similar pathologies receiving similar services
(Simpson, Foster, Kuipers, Kendall, & Hanna, 2005). The main application of this taxonomy
22
however appeared to be simply the categorisation and analysis of goal statements (i.e. what
goals set by a rehabilitation team are about). It has been suggested that this sort of
categorisation of goals could, for example, be useful for comparing or benchmarking the
rehabilitation services being offered by different services for similar populations of people
(Simpson et al., 2005). It is unclear however what this system of classification offers over
other taxonomies of functioning and disability, such as the World Health Organisation’s more
extensive and rigorously tested International Classification of Health Disability and
Functioning (ICF) (World Health Organization, 2001a) and its ‘core sets’ for acquired brain
injury (Gehy et al., 2004) or neurological conditions in general (Boldt et al., 2005; Grill, Lipp,
Boldt, Stucki, & Koenig, 2005; Stier-Jarmer et al., 2005).
This brief overview of the history of goal planning in rehabilitation, and the variation in
interpretation about how goal planning should occur, highlights a number of issues. Firstly,
while goal planning is currently presented as a fundamental component of rehabilitation, this
was not always the case: clinical rehabilitation developed without an emphasis on structured
approaches to goal planning for the better part of three quarters of a century. Secondly, even
with agreement that goal planning should form a central part of the rehabilitation process,
multiple different approaches to goal planning exist. Clinicians and rehabilitation teams are
still left with the job of deciding which approach to use in day-to-day work with patients, with
only limited empirical evidence as to which approach works best in which circumstances.
Thirdly, the literature on goal planning in rehabilitation has evolved in a somewhat
unstructured fashion, with multiple researchers and clinicians developing and promoting
different perspectives, different terminology, and different agendas. This has made the job of
consolidating the literature on goal planning in rehabilitation all the more challenging.
As a step toward developing a clearer understanding of how goal planning has been
portrayed in rehabilitation literature, the remainder of this chapter presents the method and
results from a structured literature review investigating the purposes and mechanism
attributed to goal planning in rehabilitation. To reiterate, the intent of this review is not to
present a critical appraisal of the research underpinning each hypothesised purpose or
mechanism, but rather to catalogue them in order to structure further research in this area of
study.
23
2.3 Method
Articles relevant to the following review were identified by conducting a literature

search (via Ovid) of Medline, Embase, PsychINFO and CINAHL databases from 1966 to 31
October 2004. For this search I used the subject headings ‘goals’, ‘goal attainment’, ‘goal
setting’ and text words ‘goal setting’, ‘goal planning’, ‘goal orient$’*, and ‘goal direct$’
combined with search terms recommended by the Critical Appraisal Skills Programme of the
Public Health Resource Unit to filter search findings for studies of therapeutic effect (Critical
Appraisal Skills Programme, n.d.), or combined with the subject heading ‘rehabilitation’ and
its subheadings.
The intention of this search strategy was to identify papers that described, analysed or
tested approaches to goal planning in rehabilitation or related therapy environments. To be
included in the review, papers had to meet a number of criteria. Firstly, the papers had to
describe an approach to goal planning that involved at least one patient and one therapist
(regardless of the level of patient involvement in goal selection) or that occurred within a
group setting, such as in the case of a rehabilitation team interacting with a patient and their
family or other social supports. Secondly, the articles had to be published in English (due to
the limitation of resources available for the review). Thirdly, the articles had to involve
human participants from patient populations. Thus, animal studies were excluded, as were
studies describing goal effects for non-disabled populations of students, athletes, criminals, or
members of the general public. In order to focus more on rehabilitation populations, papers
about medical decision making in acute settings (such as in the use of ‘goal-oriented’ decision
making for the management of sepsis) were also excluded.
Literature on the biomechanics of goal-oriented movement was also excluded from this
review. This excluded, for example, literature based on observational studies investigating
the influence of ‘goal-tasks’ (e.g. reaching for a cup versus reaching into midair) on motor
control (Volman, Wijnroks, & Vermeer, 2002). My justification for this exclusion was that a)
*
The ‘$’ symbol here and elsewhere in this thesis is a ‘wildcard’ used in OVID databases to represent the
addition of one or more characters at the end of the stated search term. In this case, for example, the text word
‘goal orient$’ would pick up all citations that included the terms ‘goal oriented’ or ‘goal orientation’ etc.
24
these sorts of biomechanical studies, while relevant to rehabilitation, did not appear to
constitute ‘goal planning’ in rehabilitation in its usual sense (see the definitions of ‘goal
planning’ provided in Chapter 1) and b) it was almost impossible to draw a distinction
between these sort of studies and almost any other investigation of functional retraining,
potentially making the scope of the review limitless.
Finally, due to practical constraints, unpublished theses were also excluded. Papers
were not excluded however on the basis of the publication type (i.e. this review included
experimental trials, clinical trials, descriptive studies as well as review articles, discussion
papers and opinion pieces), as it appeared that restricting article selection in this way might
limit the breadth of the review.
From the initial search strategy, I identified 1,364 citations. I screened the abstracts of
all these citations and, on the basis of the above criteria, reduced them to set of 530 citations.
In cases where I had doubts about the inclusion or exclusion of any paper, opinions of my
supervisors were sought. As a check of this process, 10% of all abstracts were independently
read for inclusion or exclusion by the research supervisors. This provided confirmation that
my original selection of papers was appropriate and that no major omissions had resulted.
I then collated the 530 abstracts according to the apparent purpose of the goal planning
described. A selection of papers from these groupings was reviewed in full with subsequent
paper selection continuing until no new or different purposes were identified. In addition, in
those cases where the purpose of goal planning was not clear within the abstract, the full
paper was also reviewed. In total this process meant that 123 papers were selected for full
review.
For included texts, I employed thematic analysis (Morse & Richards, 2002) to
qualitatively synthesise the purposes and mechanisms of goal planning that were described.
This involved reading and identifying any explicit statements regarding the functions,
purposes or mechanisms ascribed to goal planning in rehabilitation. These functions,
purposes and mechanisms were then presented to the thesis supervisors along with a proposed
framework for their classification. The framework was then debated, with particular attention
paid to its inclusiveness (whether any salient purposes or mechanisms had been omitted) and
coherence (whether the grouping of identified purposes and mechanisms was logical and
25
justifiable). Thus, through a series of discussions the framework was refined and ordered into
a typology that all agreed upon. The qualitative research concept of ‘negative case analysis’
was used during the development of this typology (Morse & Richards, 2002). This involved
the purposeful search of all abstracts and full papers for instances of goal planning that did not
fit the emerging typology. Where such examples occurred, these were used to further debate,
clarify and refine the typology.
2.4 Results
Following the above process, a preliminary typology of purposes and mechanisms
emerged. This typology was viewed as one way of clarifying the hypothesised use of goal
planning in rehabilitation. The results from this work suggested four major purposes for goal
planning:
a) Improving rehabilitation outcomes (as determined by standardised outcome

measures)
b) Enhancing patient autonomy
c) Evaluating outcomes
d) Responding to contractual, legislative or professional requirements
Each purpose was associated with one or more mechanisms, and in some cases sub-
mechanisms. The first of the above purposes for example was associated with four separate
mechanisms by which goal planning was thought to achieve its hypothesised effect. Table 2
presents a list of purposes, mechanisms and sub-mechanisms, as well as examples of their
application from current literature. To demonstrate the importance of making a critical
distinction between the various hypothesised functions of goal planning, the text following
this table illustrates how these different purposes and mechanisms may necessitate different
approaches to the practice of goal planning in rehabilitation.
26
TABLE 2: Intended purposes of goal planning in rehabilitation and their hypothesised mechanisms as described in the current literature
Purpose Hypothesised Mechanisms Hypothesised Sub-mechanisms Examples
1. To improve i) That goals can influence a a) That explicitly stated goals directly influence effort, focus, and Gauggel and Hoop (2004)
patient outcomes patient’s level of conscious persistence (striving), with this influence being moderated by Gauggel, Linberger, &
(as determined motivation factors such as goal commitment, goal difficult, goal complexity, Richardt (2001)
by standardised self-efficacy, feedback, and satisfaction with performance. Theodorakis et al. (1997)
outcome Evans and Hardy (2002)
measures) Arnetz, Almin, Bergstrom,
Franzen, & Nilsson (2004)
b) That patient satisfaction with achievement of a goal or progress Schut and Stam (1994)
towards achievement of a goal will provide a sense of reward, Tripp (1999)
which stimulates the patient to continue with or repeat the
behaviour. Reciprocally, that lack of goal achievement will de-
motivate patients.
c) That patient motivation to participate in rehabilitation activities is Maclean, Pound, Wolfe, &
enhanced when the patient perceives the goals of therapy to be Rudd (2002)
Nair (2003)
personally relevant. Goals of therapy are more likely to be
perceived as relevant when there is alignment between them and the Wade (1999a)
patient’s higher order goals (e.g. life goals), with this influence
being moderated by the patient’s understanding of the objectives of
the interventions being recommended by the rehabilitation team.
CONTINUED OVER
27
Purpose Hypothesised Mechanism Hypothesised Sub-mechanisms Examples
1. To improve ii) That goal planning can That treatment regimes such as exercise programmes, derived from Ponte-Allan & Giles (1999)
patient outcomes enhance the specificity of goal plans, which specifically train desired skills in the desired Bower, Michell, Burnett,
(as determined by therapeutic activities to environment, produce the greatest recovery of function when Campbell, & McLellan
standardised meet an individual compared to generic, non-individualised training programmes. (2001)
outcome patient’s requirements Randall and McEwen (2000)
measures) –
continued
iii) That goal planning That the process of goal planning (rather than the content of specific Nair (2003)
provides secondary goals) can have a therapeutic effect, such as retraining self- Bergquist, and Jacket (1993)
therapeutic effects, outside awareness, addressing goal-neglect, or assisting patients to Levine et al. (2000)
the scope of the goal itself psychologically adapt to a newly acquired disability.
iv) That goal planning a)That goals influence the conscious motivation and therefore the Schut and Stam (1994)
improves teamwork performance of team members Nair & Wade (2003)
Wade (1999c)
b) That goals enhance communication and collaboration between
team members
2. To enhance That goal planning can n/a Baker, Marshak, Rice, &
patient autonomy enhance patient Zimmerman (2001)
involvement in and Wressle et al. (2002)
ownership of their own
rehabilitation process
CONTINUED OVER
28
Purpose Hypothesised Mechanism Hypothesised Sub-mechanisms Examples
3. To evaluate i) That rehabilitation n/a Brown, Effgen, & Palisano,

(1998)
outcomes outcomes can be
Melville et al. (2002)
meaningfully evaluated by
measurement of observed McMillan & Sparkes (1999)
outcomes against
predicted outcomes
ii) That rehabilitation n/a Trombly et al. (2002)

outcomes can be Melville et al. (2002)
meaningfully evaluated by
measurement of patient
perceptions of their
performance against their
own pre-stated goals.
4. To meet That documenting goals Randell and McEwen (2000)

n/a
contractual, and/or evidence of the Evans et al. (2001)
legislative or process of goal planning
professional can provide a means of
requirements accountability to
professional standards,
health funders or to
legislative requirements.
29
2.4.1 Goal planning to improve patient outcomes (as determined by standardised

outcome measures)
2.4.1.1 Using goals to influence a patient’s level of conscious motivation
Goal planning has long been associated with motivation in studies of human
performance (Siegert & Taylor, 2004). However there are a number of possible explanations
regarding the way in which goal planning can influence patient motivation in the context of
clinical rehabilitation. The first explanation is that goals can directly influence a person’s
level of effort, persistence, and attention to therapeutic tasks, contributing to their self-
regulation during rehabilitation. In other words, people strive towards goals. This ‘goal
theory’ has been the subject of considerable research in industrial-organisational psychology
for over 35 years, led largely by two authors, Locke and Latham (2002). This research has in
turn influenced the application of goal planning in clinical rehabilitation (Evans & Hardy,
2002; Schut & Stam, 1994).
One core finding from the research in industrial-organisational psychology is that

specific, difficult goals produce higher levels of effort and performance when compared to
non-specific or specific, easy goals, although this effect is moderated by a number of factors
such as goal commitment, self-efficacy and task complexity (Locke & Latham, 2002). The
extent of research underlying goal theory from industrial-organisational psychology should
not be underestimated. Locke and Latham (2002) report that ‘specific difficult goals have
been shown to increase performance on well over 100 different tasks involving more than
40,000 participants in at least eight countries working in laboratory, simulation, and field
settings’ (p. 714). These findings have been recently replicated in a series of RCTs of goal
planning involving people with acquired brain injury. Specific difficult goals have resulted in
higher levels of cognitive as well as physical performance in this sample when compared to
specific easy goals, self-set goals, or non-specific goals (Gauggel & Billino, 2002; Gauggel &
Fisher, 2001; Gauggel, Hoop, & Werner, 2002; Gauggel, Leinberger, & Richardt, 2001).
Similarly, controlled trials have demonstrated that specific goals may enhance physical
performance when compared to no goals or non-specific goals for people undertaking a
quadriceps strengthening programme after knee arthroscopy (Theodorakis, Beneca, Malliou,
& Goudas, 1997), and that goal planning can result in higher levels of treatment adherence
and patient self-efficacy in a population of injured athletes (Evans & Hardy, 2002).
30
The second explanation regarding goal planning and motivation in rehabilitation is that
patients may become more motivated when they make tangible progress towards a goal or
when a goal is achieved (Maclean et al., 2002; Schut & Stam, 1994). In other words, after
attaining goals or progress towards a goal, patients are inspired to try harder with future
rehabilitation activities. In comparison to Locke and Latham’s goal theory however, there is a
far less empirical research investigating this hypothesis. One recent qualitative investigation
of patient perceptions of self-efficacy in rehabilitation reported that the ‘completion of goals
help(ed) patients to recognize explicitly what they (were) achieving’ (Dixon, 2007, p. 235).
The author linked this finding to the concept of goal attainment motivating patients to
continue with their rehabilitation (Dixon, 2007).
Associated with this explanation, is a belief that goals can have the reverse effect and be
de-motivating if patients fail to make progress. Some authors have suggested that lack of goal
attainment may make patients ‘despondent’ (Schut & Stam, 1994, p. 224). In the case of
rehabilitation for people with chronic pain Tripp (1999) advises that: ‘Any goals or aims that
are identified must be realistic and achievable, as setting unrealistic goals is doomed to end in
failure, causing further reinforcement of the sense of hopelessness’ (Tripp, 1999, p. 121).
Incidentally, some authors appear to have attempted to put a ‘dollar each way’ on the
above two theories of goal planning and motivation by stating that goals should be both
‘challenging’ and ‘achievable’ (Bassett & Petrie, 1999; Duff, Evans, & Kennedy, 2004;
Wade, 1999b). This perspective raises further questions, however, regarding how to reach a
balance between maximising striving while minimising experiences of goal failure.
Individual opinions appear to relate in part to perceived risks associated with goal failure. For
example, Tripp (1999), cited above, clearly believes goal failure should be avoided at all
costs. Locke and Latham (2002), by comparison, have hypothesised that dissatisfaction with
performance with respect to one’s goals, may in fact aid further striving, as the lack of
achievement clarifies for individuals the difference between their current state and the desired
one. Goal achievement is therefore much less important for motivation from Locke and
Latham’s (2002) perspective than factors such as goal commitment and self-efficacy, and of
course, here ‘success’ is evaluated on the basis of actual levels of performance; not on the
attainment of goals. For example, according to Locke and Latham (2002), a person with a
very difficult therapist-prescribed goal for cardiovascular fitness might not reach that goal,
31
but could still do better in their performance on a cardiovascular test (for example, the Six
Minute Walk Test) than someone who has had a much easier and therefore more ‘achievable’
goal.
The third explanation of the relationship between goal planning and motivation is that
patients become motivated to pursue rehabilitation when the goals of therapy are perceived as
being personally relevant (Maclean et al., 2002; Nair, 2003; Wade, 1999a). Some authors
have suggested that the goals of therapy can be made more relevant to patients (thus
increasing their motivation) by first identifying the patient’s ‘life goals’ before ensuring that
all goals set by the rehabilitation team align with these (Nair, 2003; Wade, 1999a). In other
words, the more personally meaningful a rehabilitation goal is to a patient, the more inclined
they will be to participate in activities that appear to lead toward it.
2.4.1.2 Using goals to enhance the specificity of training effects
In an article on goal planning in physiotherapy, Randell and McEwen (2000) contended

‘that people are likely to make the greatest gains when therapy and the related goals focus on
activities that are meaningful to them’ (p. 1199). It could be argued that the ‘meaningfulness’
of a goal primarily relates to the third explanation for goal planning influencing a person’s
motivation described above. However, Randell and McEwen (2000) focused on a proposed
relationship between an individual’s goals and the effects of training programs specifically
tailored to meet those goals. Referring to literature on motor learning, Randell and McEwen
(2000) highlighted potential benefits from targeting interventions towards active practice of
context-specific motor tasks, with goal planning being used to identify the tasks and contexts
of particular interest. Examples of research into this aspect of goal planning include two
experimental trials that investigated the effects of physiotherapy treatment based on
individualised goals versus treatment based on generic aims for children with cerebral palsy
(Bower & McLellan, 1994; Bower et al., 2001). Another potentially related study comes
from occupational therapy literature. In this study functional outcomes achieved by a cohort
of stroke patients who made functional, independence-oriented goal statements on admission
to a rehabilitation service were compared to outcomes achieved by a cohort who set less
functional goals or made no goal statements on admission (Ponte-Allan & Giles, 1999).
32
While it is not the intention of this chapter to critically appraise research into goal
planning in rehabilitation but rather to categories the hypothesised purposes and mechanisms
associated with it, it is interesting to note that Bower et al. (2001) failed to demonstrate any
statistically significant differences between improvements in motor function for children with
cerebral palsy for whom goals were set versus those for whom no goals were set. Ponte-Allen
and Giles (1999) reported a more positive finding in their study, observing that stroke patients
who made functional, independence-oriented goal statements on admission to rehabilitation
were statistically more likely to achieve better outcomes than those who did not (in terms of
changes in scores on the Functional Independence Measure from admission to discharge).
However, given that this was a cohort study rather than an experimental study, and given that
a patient’s capacity to set goals on admission might be dependent on other factors predictive
of poorer outcomes (such as cognitive functioning or depression, which were not measured in
this study), Ponte-Allen and Giles (1999) provide no evidence that this observed association
between goal set and health outcomes was a causative one.
2.4.1.3 Using goals for the purpose of a secondary therapeutic effect
Some authors have claimed that aspects of the goal planning process itself can produce
therapeutic effects in rehabilitation. For example, goal planning is sometimes described in
terms of its capacity to act as a forum for assisting patients to face and accept changes in their
life resulting from disease or disability. Nair (2003) stated that health professionals can draw
on knowledge of clinical prognosis and availability of services and resources to help patients
focus on more ‘achievable’ goals. Nair (2003) linked this with assisting patients to cope with
loss of life goals – a process that Nair believed to be ‘essential for the success of
rehabilitation’ (p. 198). The implication here is that goal planning has the additional benefit
of improving a patient’s psychological adaptation to their illness or disability (e.g. they may
be less depressed). Similarly, while Rockwood et al. (1997) are primarily concerned with the
utility of goals to measure outcomes, they too commented on the way the goal planning
process allows health professionals to negotiate with patients and their families about ‘what is
desirable and what is feasible’ (p. 586). In this way, goal planning could be regarded as a
vehicle for learning about one’s newly acquired disability, and adapting to changed
circumstances.
33
In terms of secondary therapeutic effects from goal planning, a related discussion has
occurred in rehabilitation for people with cognitive deficits. Bergquist and Jacket (1993)
argued that goal planning could be used to help a person with a self-awareness deficit gain
understanding of the value of strategies being recommended to them by a rehabilitation team.
They suggested that these patients will then be more likely to maintain outcomes following
discharge. For this reason they stated that ‘two patients with comparable functional
disabilities, but with different levels of awareness, will need different therapy goals’
(Bergquist and Jacket, 1993, p. 278).
Another example is the use of GMT to address disorganised behaviour resulting from
frontal cortex injuries. GMT is based on self-regulation theory and involves a strategy to
teach people with goal neglect (a cognitive impairment) resulting from brain injury to
moderate their behaviour during the acquisition of a new skill (Levine et al., 2000). An RCT
involving 30 people with traumatic brain injury found that GMT resulted in significantly
better improvements on everyday paper-and-pencil tasks when compared to a control group
receiving motor skills training. While cautious in their conclusions the authors of this
research suggested that goal management skills learnt through GMT may be generalisable to
everyday activities that are not specifically the focus of intervention (Levine et al., 2000).
2.4.1.4 Using goals to improve teamwork
Schut and Stam (1994) have recommended goal planning in rehabilitation for its
capacity to positively influence the functioning of rehabilitation teams. They claimed that
goal planning improves team communication, provides a structure for enhanced problem
analysis and decision making, and can motivate health professionals to make greater efforts in
rehabilitation (Schut & Stam, 1994). Clinicians have also reported they believe goal planning
helps rehabilitation teams work more ‘coherently and productively’ (Playford et al., 2000, p
494). This is a view that has also been shared by Wade (1999c).
Research into the effects of goal planning on rehabilitation teamwork is limited

however. In this review, only one observational study on the satisfaction of staff members
with goal planning meetings was identified (Nair & Wade, 2003). No studies were found that
empirically investigated the effectiveness with which goal planning improves variables
34
related to teamwork or collegial behaviour (such as feelings of team unity, collaboration on

therapeutic activities or individual motivation to pursue shared patient-related goals). In
contrast, organisational psychology literature provides substantially more research into the
effect of goals on team performance. While this literature is not specifically about
rehabilitation environments, it does suggest that it is erroneous to assume that conclusions
from research on effects of goal planning for individuals is directly transferable to goal
planning for groups of people. For example, there is some experimental evidence in the
psychological literature to suggest that goal effects on group performance is influenced by
factors such as group leadership (De Souza & Klein, 1995) and the way an individual team
member’s goals are integrated with the goals of their group (Crown & Rosse, 1995). It may
be inappropriate therefore to assume that goal planning processes designed to enhance patient
motivation or patient performance would necessarily provide the best mechanism for
maximising the function of interdisciplinary teams.
2.4.2 Goal planning to enhance patient autonomy
Discussion of ethics in rehabilitation has highlighted the importance and challenges of

recognising a patient’s right to self-determination (Blackmer, 2000; Hass, 1993; Kuczewski &
Fiedler, 2001). Beyond the hypothesised functional benefits resulting from planning
individually meaningful goals (as evaluated by standardised outcome measurement) is a belief
that patient autonomy should ultimately direct clinical decision making (Blackmer, 2000;
Hass, 1993; Kuczewski & Fiedler, 2001). Kuczewski and Fiedler (2001) wrote that ‘the
ultimate value of a proposed treatment (is) a subjective judgement, based on how they accord
with… values, goals and preferences’ (p. 849). Goal planning therefore may have a purpose
related to enhancing patient autonomy that is distinct from maximising achievement on a
standardised outcome measure. The belief in the value of goal planning to enhance patient
autonomy is reflected in observational studies of levels of patient participation in goal
planning (e.g. Baker et al., 2001) and experimental studies that evaluated the effect of goal
planning approaches on objective and subjective measures of patient participation in
rehabilitation planning (e.g. Wressle et al., 2002).
35
2.4.3 Goal planning to evaluate rehabilitation outcomes
2.4.3.1 Evaluating rehabilitation by measuring observed outcomes against predicted

outcomes
Individualised goals have also been promoted as a tool for measuring the effectiveness
of rehabilitation programs, particularly in situations where the heterogeneity of patient
populations poses problems for selection of standardised outcome measures (Rockwood,
Joyce, & Stolee, 1997). In these situations, treatments are evaluated in terms of the patient’s
level of goal achievement against predicted outcomes set at the beginning of rehabilitation.
GAS is the most common method of quantifying the relationship between predicted and
observed outcomes (Hurn, Kneebone, & Cropley, 2006; Rockwood et al., 1997). Two
examples of papers that explored the application of GAS include a study where GAS was
used to measure the effect of physiotherapy interventions for people with severe physical and
cognitive disabilities (Brown et al., 1998) and an attempt to validate the use of GAS for
clinical and research purposes in the rehabilitation of infants with motor delays (Palisano,
1993). The commentaries following both these papers highlight that GAS is not without its
criticisms (Gowland, 1993; Shelden, 1998). The selection of goals for evaluation, which is
inherently qualitative, can be open to debate (Shelden, 1998), and questions have also been
raised regarding the validity of collating data from the goals of multiple individuals
(Gowland, 1993).
As an alternative to the GAS method and its five-point scale of goal attainment, other
authors have suggested there is value in simply reporting the attainment, partial attainment or
non-attainment of goals as a measure of rehabilitation outcomes. For example, McMillan and
Sparkes (1999) audited goal attainment in 100 consecutive cases involving patients admitted
to inpatient rehabilitation for neurological problems. These authors reported a statistically
significant correlation between the number of long-term goals patients achieved during their
rehabilitation and changes in scores on two other standardised outcome measures: the Barthel
Disability Index and a 10-metre walking test (McMillan & Sparkes, 1999). Again, however,
criticisms are easily levelled against this sort of justification for using goals as outcome
measure, as the potential for bias in the goal selection process (relating them directly to items
on the Barthel Disability Index for instance) would seem high.
36
2.4.3.2 Evaluating rehabilitation by measuring patient perceptions of their performance

against their own pre-stated goals
One potential problem with the use of both GAS and simple goal attainment to evaluate
patient outcomes is that these approaches are as much a measure of the health professionals’
ability to accurately prognosticate likely outcomes as they are a measure of changes in patient
function. For instance, McMillan and Sparkes (1999) in the above example also audited the
reported reasons for non-achievement of long-term goals and concluded that the most
common reason for non-achievement was because of goals being ‘overly ambitious’ (p. 248).
This suggested that if more realistic (i.e. easier) goals had been set from the outset, the
outcomes for these patients would have been reported as being more positive. Outcome
measures based on goal attainment are therefore subject to a degree of retrospective
interpretation of the appropriateness of the particular goals set.
Other approaches to goal planning for evaluation of rehabilitation outcomes avoid this
problem by having the patients select their own goals for treatment, then measuring the
patients’ perceptions of their performance (and satisfaction with their performance) against
those goals – on initial assessment and then again at discharge. This method of goal planning
has been applied to both the COPM (Carswell et al., 2004) and the SIGA (Melville et al.,
2002). These approaches differ from GAS in that they emphasise subjective (self-rated)
evaluation of outcome rather than objective (externally observed) evaluation. As such, it has
been argued that these approaches support a more ‘patient-centred’ method of both goal
planning and outcome evaluation (Melville et al., 2002; Wressle et al., 2002).
2.4.4 Goal planning to meet contractual, legislative or professional requirements
Finally, rehabilitation professionals describe being encouraged to undertake goal

planning in order to meet the expectations of health service funders, quality auditors,
accreditation agencies and professional bodies (Evans, Zinkin, Harpham, & Chaudury, 2001;
Randall & McEwen, 2000). Randell and McEwen (2000) stated that increasingly
documentation of treatment goals is required by health care policies, reimbursement practices,
and accreditation standards. Evans et al. (2001) recommended the auditing of patient goals as
a means of evaluating the quality of rehabilitation management in community settings.
37
Certainly, in New Zealand, guidelines for rehabilitation frequently refer to the need for goal
planning processes (Accident Compensation Corporation & National Health Committee,
1998; Baskett, 1996), and Accident Compensation Corporation (ACC), a major national
agency for funding rehabilitation, requires reports on patient goals under a number of its
health provider contracts.
2.5 Discussion
This review has demonstrated that there are at least four different purposes underlying
the use of goal planning in rehabilitation and a number of different mechanisms by which
some these purposes are thought to be achieved (c.f. Table 2). Furthermore, following this
review of the literature it seems simplistic to assume that one approach to goal planning will
achieve all four purposes. For instance, goals for the purpose of measuring outcomes or for
assisting someone to come to terms with a newly acquired disability may necessitate the
selection of achievable goals. However, it would appear that achievable goals (as opposed to
difficult, challenging goals) might not necessarily encourage patients to reach maximum
levels of effort or performance on certain types of therapeutic activities in some specific
contexts. Similarly, goals for the purpose of objective outcome evaluation or maximisation of
patient performance on some rehabilitation activities require the use of measurable goals.
This may conflict with goal planning for the purpose of enhancing patient autonomy if a
patient is more interested in experiential goals (such as goals relating to spiritual, cultural, or
social relationships). Furthermore goal planning to enhance patient autonomy carries with it
the requirement that goals should not be ‘set in stone but must be continually revisited and
revised’ (Kuczewski & Fielder, 2001, p. 849). This flexible, open-ended approach might not
be appropriate for other purposes or mechanisms of goal planning, such as enhancing
performance on specific physical tasks or meeting the expectation of funding agencies (where
contracting may impose a number of limits to flexibility).
Similarly, distinguishing between different hypothesised mechanisms underlying the

use of goal planning can also provide some insight into why recommended approaches to goal
planning in rehabilitation can differ so substantially. For example, this review identified three
possible sub-mechanisms regarding the influence of goal planning on patient motivation. The
38
first of these hypothesised sub-mechanisms, derived from Locke and Latham’s (2002) goal
theory, requires goals to be challenging and specific, with patients only needing to think they
are attainable to be committed to them (Gauggel & Hoop, 2004). The second hypothesised
sub-mechanism requires that goals (or at least progress towards a goal) be attained before one
can expect a positive influence on motivation (Schut & Stam, 1994). ‘Achievable’ goals and
avoidance of goal failure are therefore required. The third explanation requires substantially
different information (the patient’s life goals) to be collected and incorporated in to clinical
decision making and communication with the patient (Nair, 2003).
Such examples illustrate how different reasons for undertaking goal planning may
require different approaches to its implementation. This has implications for research as well
as clinical practice. Thus, while there is definitely a need for further research to be conducted
on goal planning approaches in rehabilitation (as has been suggested by Nair, 2003; Nair &
Wade, 2003; and Playford et al., 2000), when embarking on this work authors should be
explicit about their intended purpose for goal planning as well as the hypothesised
mechanisms by which goals are thought to achieve these desired effects. Furthermore,
specifying the proposed mode of action or mechanism of the goal planning will make explicit
the outcomes that should be measured in such studies. It may also be beneficial for
researchers to pay attention to potential secondary effects from goal planning that are not
necessarily the focus of a study. For example, studies into the effects of specific difficult
goals on patient performance could be balanced with reports of patient satisfaction regarding
both the process of rehabilitation and outcomes achieved.
Systematic reviews of the literature on goal planning in rehabilitation may also benefit
from attention to the purposes and mechanisms of goal planning. One approach would be to
stratify or limit the inclusion of studies for such reviews, possibly using the typology that I
have presented here. This approach is taken in Chapter 3 of this thesis, where a systematic
review is undertaken to investigate the effectiveness of goal planning to achieve the first of
these purposes – that of improving patient outcomes as determined by standardised outcome
measures.
Similarly, when clinicians are reviewing literature in order to make decisions about
which approach to goal planning they should adopt, or when they are considering the findings
from a research paper that challenges their current approach, they might wish to first consider
39
what it is they want to achieve through goal planning. Is the purpose of goal planning in their
practice to enhance their patient’s involvement in clinical decision making? Or to improve
their teamwork? Or to motivate patients to a higher level of effort on set tasks? Or for some
other reason? It may even be that different groups of patients in different rehabilitation
settings respond most positively to different approaches. For instance, in sports rehabilitation
settings, where patient autonomy is perhaps less at risk, specific difficult goals may result in
the highest levels of effort on therapeutic activities and therefore the best of clinical
outcomes. Conversely, in post acute residential rehabilitation for people with traumatic brain
injury, achieving patient participation in clinical decision making may be more challenging.
In such a situation, secondary effects from goal planning (such as improved self-awareness)
may be more desirable.
A further consideration is the organisational context in which rehabilitation is provided.

Some clinicians may find that factors such as reimbursement practices, contractual obligations
and accreditation standards largely dictate the way in which goal planning is to occur in their
particular area of rehabilitation. Randall and McEwen’s (2000) recommendations for goal
planning for instance seem somewhat influenced by external factors specific to the physical
therapy industry in North America. Of course, existence of such contextual factors should not
stop clinicians and researchers from participating in the ongoing debate regarding the best
way to approach goal planning to maximise quality of services for patients.
It is however, important to recognise the provisional nature of the typology described in

this chapter. It is worth reiterating that approaches to goal planning can potentially be
categorised in other ways, including the intended clinical context (e.g. inpatient, community,
or residential settings), the target patient population, or the intended professional group(s)
using the approach. Literature from these different categories may well emphasise and utilise
different purposes for goal planning.
One other limitation of this preliminary typology is that it risks suggesting that
individual approaches to goal planning (e.g. GAS, COPM, SIGA or SMART approaches) can
be attributed with a single purpose and mechanism. In fact, frequently in the literature
multiple purposes and mechanisms are attributed to one goal planning approach (Baker et al.,
2001; Conneeley, 2004; Malec, 1999; Randall & McEwen, 2000; Wade, 1999c). For
example, while the original purpose of GAS was to provide an approach to individualised
40
outcome measurement (Kiresuk & Sherman, 1968), the literature on GAS in rehabilitation
also attributes this approach with: enhancing teamwork; enhancing clinical decision making;
enhancing communication with the patient, their family, the referring body, and the funding
source; as well as, in the case of brain injury, addressing impaired self-awareness and goal
management deficits (Malec, 1999; Rockwood et al., 1997). What the typology described in
this chapter does offer is a way of critically engaging with literature such as this. Thus,
reading the literature on GAS more closely, it becomes apparent that not one, but multiple
approaches to goal planning are in fact being described. Malec (1999) for example discusses
the importance of setting smaller, short-term goals that act as steps towards achievement of a
GAS goal and describes how the process for establishing goals for people with self-awareness
deficits should differ from standard GAS approaches. No distinction is made by Malec
(1999) regarding the different purposes for these separate approaches, making it very difficult
to empirically investigate whether each approach can be considered effective or not.
One final complexity here relates to the epistemologically different arguments used to
justify different purposes for goal planning. Some of the literature on goal planning is based
on empirical evidence, such as the positivist research of Gauggel and colleagues (Gauggel &
Billino, 2002; Gauggel & Fisher, 2001; Gauggel et al., 2002; Gauggel et al., 2001), while
other authors rely more heavily on ideological or philosophical arguments to justify their
perspectives, such as in the use of goal planning to enhance patient autonomy (Blackmer,
2000; Hass, 1993). In this chapter, value judgements have not been made about these
different perspectives. Indeed, it is not even assumed at this stage that a unified theory of goal
planning in rehabilitation necessarily needs to exist. Instead an attempt has been made to
differentiate between the proposed purposes of goal planning in order to provide a framework
within which research, reviews and clinical opinions can be more critically considered.
Further work is required to unravel the subtleties of each purpose, within each epistemology
and within each clinical context.
41
2.6 Conclusion
This chapter has presented a preliminary typology of purposes for undertaking goal
planning in rehabilitation and proposes the underlying mechanisms and sub-mechanisms by
which these purposes are thought to be achieved. The typology was derived from a structured
analysis of the literature in which thematic analysis was used to analyse the qualitatively
different reasons for employing goal planning in clinical rehabilitation. I have suggested here
that when conducting research into goal planning in rehabilitation or when applying research
to clinical practice, researchers and clinicians should be explicit about what they hope to
achieve through goal planning and how they hope to achieve this. In the following chapters,
this typology is used as a framework for structuring a systematic review into the effectiveness
of goal planning in rehabilitation (cf. Chapter 3) and for gaining greater theoretical sensitivity
to data gathered during grounded theory investigations of goal planning in clinical practice
(cf. Chapters 5 and 6).
42
Chapter 3: Effectiveness of goal planning in rehabilitation – a systematic review
Chapter 3: Effectiveness of goal planning in rehabilitation – a

systematic review
3.1 Introduction
The previous chapter introduced the notion that goal planning may serve a range of
possible purposes in rehabilitation, with some purposes having a number of hypothesised
mechanisms and sub-mechanisms by which goal planning was thought to achieve its desired
effect (c.f. Table 2, p. 27-29). This chapter reports the findings from a systematic review of
the literature to identify and critically appraise the best available evidence regarding the
effectiveness of goal planning to achieve one of these purposes: that of improving
rehabilitation outcomes (as determined by standardised outcome measures). This work is
important because, despite a general consensus that goal planning is an essential part of
contemporary rehabilitation practice (Baker et al., 2001; Barnes & Ward, 2000; Conneeley,
2004; Duff et al., 2004; Elsworth, Marks, McGrath, & Wade, 1999; Kuipers et al., 2003;
Lawler et al., 1999; McMillan & Sparkes, 1999; Playford et al., 2000; Randall & McEwen,
2000; Rothstein et al., 2003; Siegert & Taylor, 2004; Simpson et al., 2005; Wade, 1999d;
Wressle et al., 2002; Wressle et al., 2003; Wressle, Öberg, & Henriksson, 1999), little
agreement exists regarding the best way to undertake goal planning. As a result, there have
been increasing calls for critical investigation into the effectiveness of goal planning in
rehabilitation (Nair, 2003; Nair & Wade, 2003; Playford et al., 2000; Siegert & Taylor, 2004;
Wade, 1998).
In 1979, Cytrynbaum and colleagues published a review of the use of GAS, which, as
previously mentioned, was perhaps the earliest structured approach to goal planning in
rehabilitation. At this time, Cytrynbaum et al. (1979) noted that while GAS was initially
devised as an outcome measure, there was growing support for it to be used as a therapeutic
intervention. However Cytrynbaum et al. (1979) concluded that ongoing research was
required to further clarify the ‘critical and influential parameters’ (p36) of GAS in this regard.
More research into the therapeutic effectiveness of goal planning was called for.
Since then, a number of narrative reviews concerning goal planning in rehabilitation

have been published covering a range of approaches (Malec, 1999; Wade, 1998, 1999a) but
evidence regarding ‘effectiveness’ has yet to be summarised in a systematic review. Recently
43
a review based on a systematic search of the literature for one potential approach to goal
planning, the COPM, was published (Carswell et al., 2004). This review however provided
no assessment of the methodological quality of studies looking at therapeutic effect and as
such, provided no synthesis of evidence regarding the effectiveness of the COPM to improve
clinical outcomes.
Other systematic reviews have been published that incorporated goal planning as one
part of the interventions under investigation, but frequently these reviews have not separated
the effects of goal planning from other ‘non-pharmacological’ or ‘psychological’ strategies
being investigated (Ellis et al., 2004; Norris et al., 2005; Rees, Bennett, West, Davey, &
Ebrahim, 2005). One exception to this has been the publication of a meta-analysis of
evidence regarding the effectiveness of self-regulation therapy in the treatment of ‘adult
behavioural problems’ (Febbraro & Clum, 1998). In this review, the additive effect of goal
planning on other types of self-regulation treatment was investigated (Febbraro & Clum,
1998). However, the search strategy of this review was limited to psychological databases
only (Febbraro & Clum, 1998). Furthermore, studies of goal planning effects included in the
review involved populations of non-disabled people with general health concerns (such as
weight loss) rather than populations of people with disabilities participating in rehabilitation
interventions (Febbraro & Clum, 1998).
A rigorous, well-defined systematic review of the evidence regarding the therapeutic

effect of goal planning in rehabilitation was therefore clearly required. One of the challenges
involved with undertaking such a review however is the lack of consistently used or agreed
definitions for a number of the key terms, in particular, for the terms ‘goals’, ‘goal planning’
and ‘rehabilitation’. While definitions of these terms have been provided in the introduction
to this thesis, there are still some issues regarding their operationalisation that require further
discussion. For example, Wade (1998) has defined goal planning (in part) as ‘the process of
agreeing on goals, this agreement usually being between the patient and all other interested
parties.’ (p273). However, not all experimental studies investigating approaches to goal
planning in rehabilitation have necessarily been based on goals that were ‘agreed’. Indeed,
there are some studies that have investigated the effect of goals that were prescribed for (not
negotiated with) a patient (Cross & Parsons, 1971; Gauggel & Hoop, 2004). For this reason
goal planning, in this review, has been referred to more broadly as the ‘establishment of
goals’. Some researchers and clinicians might argue that there are a number of other
44
objective characteristics of goal planning in rehabilitation, such as the need for goals to be
‘specific’, ‘measurable’, ‘achievable’, and/or ‘patient-centred’(Barnes & Ward, 2000).
Arguably however elements of goal planning such as these are precisely what needs to be
established through the logical and systematic application of empirical data. Therefore these
additional criteria (or any other proposed characteristics associated with goal planning) were
not used to further limit the scope of this systematic review.
Likewise, defining the term ‘rehabilitation’ for the purposes of a systematic review was
equally problematic. Definitions such as the one provided by the World Health Organisation
in the introduction to this thesis tend to very broad (see page 5), making it difficult to
determine what (if anything) is outside the scope of ‘rehabilitation’. This problem was
addressed by narrowing the scope of the review to include only those studies that tested
theories of goal planning in rehabilitation populations. Here ‘rehabilitation populations’ was
operationalised by defining them as any non-acute population of people with one of an
extensive list of pre-selected diseases, disorders or injuries. This decision (to focus the review
specifically on studies involving people with disabilities) was made because it was deemed
important to test theories of goal planning in such rehabilitation populations rather than to
assume generalisability from research on non-disabled populations (e.g. psychology students,
elite athletes etc.).
Due to the complexities described above with limiting the scope of this review, a
decision was made to restrict this review to only those studies that employed research
methods which provided the best empirical evidence of therapeutic effect, in other words on
studies utilising RCT designs (Domholdt, 2005). The aim of this review therefore was to
employ methods of systematic review in order to identify and critically appraise all RCTs
involving adult rehabilitation populations regarding the effectiveness of goal planning to
positively influence patient outcomes (as determined by standardised outcome measures) or to
influence factors contributing to these outcomes.
45
3.2 Method
3.2.1 Literature search
A computerised literature search was conducted in Ovid on Medline, Embase,

PsycINFO, CINAHL, and AMED databases as well as in the Cochrane Central Register of
Controlled Trials, the Cochrane Database of Systematic Reviews, the American College of
Physicians Journal Club database, and the Database of Abstracts of Reviews of Effects. The
search was limited to studies involving adult participants published in English between 1966
and 30 June 2005. Searches were conducted using the subject headings ‘goals’, ‘goal
attainment’, ‘goal setting’ and text words ‘goal setting’, ‘goal planning’, ‘goal direct$’, and
‘goal orient$’. These were combined with the search terms recommended by the Critical
Appraisal Skills Programme of the Public Health Research Unit, in order to filter search
findings for studies of therapeutic effect (Critical Appraisal Skills Programme, n.d.). In
addition to this, the reference lists for all studies for which hardcopies were obtained were
examined as were the reference lists of any previous systematic reviews identified through
this search strategy.
The title and abstract of each article, and the full article where necessary, were
independently screened against the inclusion criteria by two reviewers: I was one of the two
reviewers; the second reviewer was a research assistant, who was a psychology honours
graduate, trained in systematic review methods. Differences in agreement between the
reviewers, which occurred for 8% (n=82) of the citations screened, were resolved by
consensus, discussion within the study team and/or arbitration by a third reviewer (one of the
thesis supervisors). To be included in the systematic review, studies were required to meet all
of the following criteria: (1) be published in a peer-reviewed journal; (2) report an original
RCT; (3) involve adult research participants; (4) involve populations of patients with post-
acute or chronic disabling conditions resulting from one of the following, as defined by the
World Health Organisation’s International Statistical Classification of Diseases and Health
Related Problems (ICD-10) (World Health Organization, 1992): injuries, burns, or diseases
(excluding those of congenital or developmental origin) of the musculoskeletal system or
connective tissue, the skin or subcutaneous tissue, the respiratory system, the circulatory
system, the nervous system or the endocrine, nutritional or metabolic systems, or any mental
or behavioural disorders (excluding those relating to psychoactive substance use, mental
46
retardation, or psychological development), and (5) involve an aspect of goal planning or

approach to goal planning as one of the independent variables under investigation.
To meet this last criterion, studies were required to randomly allocate patients to one of
at least two groups, providing an aspect of goal planning or approach to goal planning to one
group of patients, while controlling for this aspect or approach in the second group. Studies
in which goal planning formed only part of a whole programme of rehabilitation were
excluded in circumstances where outcomes of the intervention could not be specifically
attributed to goal planning. For the purposes of this review, an ‘aspect of goal planning’
included any of the following: identification and/or documentation of goals for treatment or
rehabilitation, stakeholder involvement in goal selection (including but not limited to patient
involvement), feedback to patients on their performance towards pre-specified goals,
encouragement to attain specified goals (where generic encouragement was adequately
controlled for), and development of a plan or provision of information regarding how to attain
goals (where generic education and/or levels of health professional contact was adequately
controlled for). Also note, the term ‘post-acute’ in the above inclusion criteria was intended
in its broadest possible sense with the primary intent of excluding studies that investigated the
effect of goal-directed decision making by medical staff in emergency or intensive care
settings or in the management of acute medical conditions, such as sepsis.
3.2.2 Methodological quality
The quality of all identified papers was evaluated using the Physiotherapy Evidence
Database (PEDro) scale (Sherrington, Herbert, Maher, & Moseley, 2000). This scale was
chosen because the reliability of data obtained from it has been supported by empirical testing
and because it has been widely used in other reviews of rehabilitation (Foley, Teasell, Bhogal,
& Speechley, 2003; Maher, Sherrington, Herbert, Moseley, & Elkins, 2003; Teasell, Foley,
Bhogal, & Speechley, 2003). The PEDro Scale grades all studies on 11 items. Total PEDro
scores equal the number of satisfied items on the scale, except for the first item which
evaluates the external validity (applicability) rather than internal validity of a study
(Sherrington et al., 2000). Using this scale, all papers were therefore given a total PEDro
47
score of zero to ten points*. Low PEDro scores were not used to exclude studies, but rather to
provide context for discussion of the relative strengths and weaknesses of evidence arising
from all included studies.
The methodological quality of all papers was independently assessed by the same two
reviewers. Inter-rater reliabilities of individual items of the PEDro scale were calculated by
Cohen’s kappa. Disagreements were resolved by discussion within the study team, and where
needed, by arbitration with a third reviewer (one of the thesis supervisors) or, occasionally, by
a health research statistician.
3.2.3 Data extraction
For each included study, data were extracted on: the PEDro scale item scores, the total
PEDro score, the patient population, the clinical context of the study, the hypothesised
purposes and/or mechanism of goal planning under investigation, any descriptions of the
intervention and control groups, and the reported results of the study including size of effects
and significance of any observed group differences. Data extraction was again conducted
independently by the two reviewers using a standardised form. Disagreements were resolved
by discussion, and where needed, arbitration by a third reviewer (again, one of the thesis
supervisors). If data were missing from any paper, attempts were made to contact the first
author to include the information necessary for critical appraisal. Studies that were published
in duplicate were only included once.
3.2.4 Data analysis
Ideally, a quantitative synthesis (or meta-analysis) of the data from the included studies
would have been performed. This however was not possible due to the high degree of
variability between studies regarding the approach to goal planning under investigation, the
types of populations studied, and the outcomes selected for measurement. Best-research
*
A more detailed description of the list of items, their definitions and grading criteria for the PEDro scale is
available on the PEDro website (www.pedro.fhs.usyd.edu.au/index.html).
48
synthesis was therefore used instead. Using a system similar to that employed by van Tulder
and Cherkin, Berman, Lao, & Koes (1999) and Maher (2000), statements on the therapeutic
effectiveness of goal planning in rehabilitation were based on the quality, amount and
consistency of evidence from the identified RCTs:
• Strong evidence: More than one high quality RCT with consistent outcomes
• Moderate evidence: One high quality RCT and one low quality RCT with consistent
outcomes
• Limited evidence: One high quality RCT or more than one low quality RCT with
consistent outcomes
• No evidence: One low quality RCT, no RCTs or inconsistent outcomes.
A trial was considered to be of high quality if it had a total PEDro score of 6 or more
(Maher, Sherrington, Herbert, Moseley, & Elkins, 2003). To test the sensitivity of this cut
off, as suggested by Maher et al. (2003), recommendations resulting from alternative cut off
scores of 4 or 5 were compared with those resulting from the cut off score of 6. Outcomes
from studies were considered ‘consistent’ if 75% or more of the studies reported the same
outcome.
3.3 Results
A 'QUOROM' style flowchart (Moher et al., 1999) for the selection of studies included
in this review is provided in Figure 2. The initial search of all electronic databases identified
1052 potentially relevant articles published between 1966 and 30 June 2005. After screening
the titles and abstracts for these articles, excluding those that did not meet the inclusion
criteria for this review, 77 articles were selected. Full-text copies were obtained for all 77
papers. An additional 16 articles were added to this list following a search of all
bibliographies in papers obtained for this review. From this total pool of 93 articles, 71 were
excluded on the basis of failure to meet the inclusion criteria for this review when the full-text
copy was appraised. Of the remaining 22 articles, five were publications relating to only two
separate studies (Duncan & Pozehl, 2003; Duncan & Pozehl, 2002; Ostelo et al., 2003;
Ostelo, Goossens, de Vet, & van den Brandt, 2004; Ostelo et al., 2000). A total of 19 studies
therefore met the criteria for inclusion in the data analysis.
49
FIGURE 2: Process for inclusion of studies in the systematic review
Full citations obtained for all

potentially relevant papers, excluding
animal studies and those not in English,
and screened for retrieval (n=1052)
975 papers excluded, with reasons:
• Not in a peer-review journal (n=97)
• Did not involve patients as study participants (n=316)
• Did not involve adult patient populations (n=5)
• Did not involve post-acute or chronic disabling conditions resulting from one of the following, as defined by the ICD-10:
diseases of the musculoskeletal system, connective tissue, skin, subcutaneous tissue, respiratory system, circulatory system,
nervous system, endocrine system, or nutritional or metabolic diseases, injuries, burns, or mental or behavioural disorders
(n=107)
• Involved populations of patients with disorders related to psychoactive substance use, as defined by the ICD-10 (n=50)
• Did not report an original randomised controlled trial (n=311)
• Did not involve an approach to or aspect of goal planning as one of the independent variables under investigation (n=89)
Full-text copies of remaining papers

were obtained (n=77), PLUS additional
full-text copies obtained from
bibliographies (n=16), (total n = 93)
71 papers excluded, with reasons:
• Full study not published in a peer-review journal (n=3)
• Did not involve patients as study participants (n=6)
• Did not involve post-acute or chronic disabling conditions resulting from one of the ICD-10 disease, disorders or injuries
listed in the box above (n=1)
• Did not report an original randomised controlled trial (n=32)
• Did not involve an approach to or aspect of goal planning as one of the independent variables under investigation (n=29)
Papers to be included in the systematic review (n=22), adjusted for

studies published in more than one paper (one study published in two
papers, another published in three papers) = Total number of studies to
be included in the systematic review (n=19)
50
3.3.1 Methodological quality of included studies
PEDro items scores and total PEDro scores for all included studies are presented in
Table 3. Cohen’s kappa, as an estimate of initial agreement between the two raters on the
methodological quality of the 19 included studies, was 0.80. This indicated that the raters
began with a high level of agreement regarding items on the PEDro scale for individual
papers, before engaging in debate over aspects of methodological quality where initial opinion
differed (Maher et al., 2003).
Four of the included studies used cluster randomisation to allocate patients to

intervention or control groups (Bell, Lysaker, & Bryson, 2003; Blair, 1995; Blair, Lewis,
Vieweg, & Tucker, 1996; Sperduto, Thompson, & O'Brien, 1986). For these studies, scores
for between-group comparisons and point and variability estimates were only given if the
analysis producing these figures was appropriate for this type of randomisation. While some
points were awarded in this regard, none of these studies appeared to consider the use of
cluster randomisation in the description given for statistical analysis of their data.
51
TABLE 3: Comparison of PEDro scores for included studies
Point estimates & variability

Between-group comparisons
Intention-to-treat analysis
Baseline comparability
Total PEDro Score**

Concealed allocation
Adequate follow-up
Random allocation
Eligibility criteria
Blind therapists
Blind assessors
Blind subjects
Citation*
Arnetz et al. (2004) 4
Bassett & Petrie (1999) 4
Bell et al. (2003)*** 4
Blair et al. (1996)*** 4
Blair (1995)*** 4
Cross & Parsons (1971) 4
Duncan & Pozehl (2002, 2003) 4
Gauggel & Billino (2002) 9
Gauggel & Fischer (2001) 7
Gauggel et al. (2001) 9
Gauggel et al. (2002) 9
Hart (1978) 4
Howell (1986) 2
Levine et al. (2000) 4
Mann & Sullivan (1987) 5
Ostelo et al.(2003), Ostelo et al.
8
(2004), Ostelo et al. (2000)
Scott, Setter-Kline, & Britton
6
(2004)
Sperduto et al. (1986)*** 3
Webb & Glueckauf (1994) 4
* Details regarding patient populations and research methods for these studies are included in
the evidence tables for this chapter (c.f. Tables 4, 5, and 6; p. 55, p. 61, and p. 63 respectively)
** The ‘eligibility criteria’ item does not contribute to total score
*** Studies that involved cluster randomisation
52
3.3.2 Patient populations and study contexts
Of the 19 included studies, therapeutic effects of goal planning were investigated in

populations of people with musculoskeletal disorders (Arnetz et al., 2004; Bassett & Petrie,
1999; Cross & Parsons, 1971; Ostelo et al., 2003; Ostelo, Goossens, de Vet, & van den
Brandt, 2004; Ostelo et al., 2000), disorders or injuries of the central nervous system
(Gauggel & Billino, 2002; Gauggel & Fisher, 2001; Gauggel et al., 2002; Gauggel et al.,
2001; Levine et al., 2000; Webb & Glueckauf, 1994), mental health conditions (Bell et al.,
2003; Hart, 1978; Howell, 1986), cardiovascular pathologies (Duncan & Pozehl, 2003;
Duncan & Pozehl, 2002; Mann & Sullivan, 1987; Scott et al., 2004), endocrine/dietary
disorders (Sperduto, Thompson, & O'Brien, 1986), and in populations of frail elderly in
residential care (Blair, 1995; Blair et al., 1996). For six of the included studies, the immediate
effects of goal planning on patient behaviour were investigated over a short period of time,
such as a few hours or within the context of a few days (Cross & Parsons, 1971; Gauggel &
Billino, 2002; Gauggel & Fisher, 2001; Gauggel et al., 2002; Gauggel et al., 2001; Levine et
al., 2000). For the other 13 studies, the effects of goal planning were observed in the context
of treatment and rehabilitation provided in residential, outpatient, community-based or
inpatient services, over a period of weeks or months.
In all studies, structured approaches to goal planning were employed using standardised
forms and/or standardised processes. For the 13 studies that investigated the effects of goal
planning on patient outcomes following a rehabilitation programme, nine studies investigated
the effects of collaborative approaches to goal planning, whereby formal processes were used
to negotiate the selection of goal with patients (Arnetz et al., 2004; Bell et al., 2003; Blair,
1995; Blair et al., 1996; Hart, 1978; Howell, 1986; Mann & Sullivan, 1987; Ostelo et al.,
2003; Ostelo et al., 2004; Ostelo et al., 2000; Scott et al., 2004); two investigated the effects
of prescribed goals, where goals were set on behalf of patients by the health professionals
(Duncan & Pozehl, 2003; Duncan & Pozehl, 2002; Sperduto et al., 1986); one investigated the
effects of both collaboratively set and prescribed goals (Bassett & Petrie, 1999); and one
investigated the effects of the level of involvement of patients in a collaborative approach to
goal selection (Webb & Glueckauf, 1994). In addition to this, six of these studies investigated
approaches to goal planning that involved regular (typically weekly) meetings to discuss
feedback on progress towards established goals and revision of those goals (Bell et al., 2003;
Hart, 1978; Howell, 1986; Ostelo et al., 2003; Ostelo et al., 2004; Ostelo et al., 2000;
53
Sperduto et al., 1986). Three studies incorporated formal processes for patients to self-monitor
their progress towards goals (Duncan & Pozehl, 2003; Duncan & Pozehl, 2002; Mann &
Sullivan, 1987; Sperduto et al., 1986).
3.3.3 Effect of goal planning on rehabilitation programme outcomes
The effect of approaches to goal planning on outcomes following clinical rehabilitation

programmes was reported on in 13 studies. The results from these studies however were
inconsistent, with as many high and low quality studies reporting no significant effects
(Bassett & Petrie, 1999; Duncan & Pozehl, 2003; Howell, 1986; Mann & Sullivan, 1987;
Ostelo et al., 2003; Ostelo et al., 2004) as those reporting statistically significant differences
between the study groups (Arnetz et al., 2004; Bell et al., 2003; Blair, 1995; Blair et al., 1996;
Hart, 1978; Scott et al., 2004; Sperduto et al., 1986; Webb & Glueckauf, 1994) (see Table 4).
Therefore while positive therapeutic effects of goal planning have been observed in some
individual studies, there is no evidence of generalisable therapeutic effects attributable to goal
planning in clinical rehabilitation. Analysis of subgroups of studies based on the type of
approach used for goal planning (e.g. using collaborative versus prescribed goals or goal
planning with regular feedback versus goal planning without specified processes for
feedback) did not alter this finding. The finding was also unaffected by changing the cut-off
score that defined a ‘high quality’ study from a total PEDro score of 6 to a less conservative
score of 5 or 4.
54
TABLE 4: RCTs on the effect of goal planning on treatment outcomes (ordered by total PEDro score)
Reference Total n* Patient Population Aspect or approach to goal Main Results**
PEDro planning under investigation
Score
Ostelo et al. 8 105 First-time lumbar disc Provision of a) individually graded No significant difference between the
(2003) (105) surgery patients, with functional exercises toward pre- groups at 6 and 12 months regarding
persisting low back specified, collaboratively-set goals functional status, pain, pain catastrophising,
pain or sciatica 4-6 within a set timeframe, with therapists fear of movement, range of motion, general
weeks after surgery, reinforcing patient’s achievements health, social functioning, or return to
receiving and disregarding pain versus b) ‘usual work.
physiotherapy care’.
Scott et al. 6 88 Patients with heart Provision of a) nursing-delivered In comparison to the other two groups, the
(2004) (66) failure receiving education about self-management collaborative goal planning approach to
education about self- strategies specific to heart failure education resulted in significant
management versus b) collaboratively set goals improvements on Mental Health Inventory-
relating to self-management of heart 5 scores and Quality of Life Index scores at
failure, with targeted nursing- 6 months.
delivered education to assist the
patient in goal achievement, versus c)
education about health promotion not
specific to heart failure.
* The first number refers to the number of people enrolled in the study. The second number (in brackets) refers to the number of people included in the
data analysis for primary outcomes.
** All between-group comparisons are statistically significant (p<0.05) unless otherwise stated
CONTINUED OVER
55
Reference Total n Patient Population Aspect or approach to goal Main Results

Score
Mann & 5 66 Patients with Provision of a) task-centred education No significant difference between groups
Sullivan (56) hypertension receiving versus b) task-centred education with regarding self-reported sodium intake or
(1987) education to improve the addition of collaboratively-set urinary sodium excretion at 3 months.
their diet behavioural goals and self-monitoring
regarding progress toward these
goals, versus c) no education or goals.
Arnetz et al. 4 77 Rheumatology patients Provision of a) a formally structured Structured, collaborative goal planning
(2004) (71) receiving process for collaborative resulted in significant improvements and
physiotherapy identification and selection of better goal achievement in pain reduction,
treatment goals within three domains: range of movement, strength and functional
pain, physical ability and functional ability compared to the control group, but
ability versus b) goals assigned by the not for balance, general fitness or walking
physiotherapist, and discussed or ability. Outcomes were measured for less
negotiated with the patient at the than 85% (n<67) of the patient population
physiotherapist’s discretion. however for all domains except pain
reduction.
Bassett & 4 74 Patients with upper or Addition of either a) goals for No significant difference between the
Petrie (1999) (66) lower limb injury treatment being set collaboratively groups regarding amount of ‘relief’
receiving with the patient, or b) goals for obtained from physiotherapy.
physiotherapy treatment being mandated by the
physiotherapist versus c) no formally
set goals.
CONTINUED OVER
56

Score
Bell et al. 4 74 People with Provision of a) collaborative goal In comparison to ‘usual supports’, regular
(2003) (63) schizophrenia or planning and evaluation in a weekly collaborative goal planning and evaluation
schizoaffective group meeting format versus b) in a group format resulted significantly
disorder undertaking a ‘supports as usual’. greater: weeks worked, hours worked and
paid work trial scores on the Work Behavior Inventory.
Blair et al. 4 15 Older adults in nursing Provision of a) training to staff in At 22 weeks, the older adults whose
(1996) (15) homes with disabilities collaborative goal planning and nursing staff had received training in
resulting in activity operant behavioural management collaborative goal planning and operant
limitation versus b) training to staff in just goal behavioural management achieved
planning versus c) no training in significantly higher Goal Attainment Scale
collaborative goal planning or scores for individually pre-selected self-
behavioural management. care activities in comparison to the older
adults whose staff received no training. No
such difference was reported for the group
whose staff received training in just
collaborative goal planning.
Blair (1995) 4 89 Older adults in nursing Provision of a) training to staff in In comparison to the other two group, the
(79) homes with disabilities collaborative goal planning and older adults whose nursing staff had
resulting in activity operant behavioural management received training in collaborative goal
limitation versus b) training to staff in just planning and operant behavioural
operant behavioural management management achieve significantly higher
versus c) no training in collaborative Goal Attainment Scale scores for
goal planning or behavioural individually pre-selected self-care
management. activities.
CONTINUED OVER
57

Score
Duncan & 4 16 Patients with heart Provision of a) prescribed goals for No significant differences between the
Pozehl (14) failure undertaking frequency and duration of home group in terms of changes in VO2 max or
(2003) home-based exercises exercises plus forms for patients to scores on the 6-minute walk test, Baseline
following the self-monitor their goal achievement Dyspnoea Index, the Piper Fatigue Scale, or
completion of a versus b) no goals. the Minnesota Living with Heart Failure
supervised 12-week questionnaire.
exercise programme.
Webb & 4 16 Patients with traumatic Provision of rehabilitation where High involvement in goal planning resulted
Glueckauf (11) brain injury receiving patients have a) high involvement in in significant improvements in Goal
(1994) day treatment at a goal planning versus b) low Attainments Scale scores at 2 months in
neurological involvement in goal planning. comparison to low involvement in goal
rehabilitation centre. planning.
Hart (1978) 4 32 People with mental Provision of a) collaboratively set At three months, the group receiving
(32) health illnesses goals with weekly structured regular feedback, sub-goals, and
receiving three months feedback, collaboratively set sub- ‘assignments’ achieved significantly higher
of individual goals and ‘assignments’ to achieve changes in Goal Attainment Scale scores
psychotherapy these goals versus b) collaboratively than the group who did not receive such
set goals at the beginning of additional input.
psychotherapy with no further
feedback or discussion on these goals.
CONTINUED OVER
58

Score
Sperduto et 3 173 People with clinical Provision of a) prescribed behavioural At three months, the groups receiving
al. (1986) (not obesity undertaking a goals, modified at weekly meetings as prescribed goals, self-monitoring forms and
reported) weight loss participants progressed, as well as goal feedback had achieved significantly
programme self-monitoring forms and feedback greater weight loss when compared to the
versus b) no prescribed goals. control group.
Howell 2 27 People receiving Provision of a) weekly collaborative No significant differences between the
(1986) (17- occupational therapy goal planning and evaluation versus groups on: Goal Attainment Scale scores,
22) for psychiatric b) weekly positive feedback. the Griffiths Work Performance Scale or
disorders the Shepherd Social Behaviour Rating
Scale.
59
3.3.4 Effect of goal planning on patient motivation and/or treatment adherence
The effect of goal planning approaches on adherence to rehabilitation programmes was

evaluated in four studies (Bassett & Petrie, 1999; Duncan & Pozehl, 2003; Duncan & Pozehl,
2002; Howell, 1986; Sperduto et al., 1986). A fifth study investigated the effect of prescribed
goals on adherence to clinical advice over a short period (three days) following the provision
of the goal (Cross & Parsons, 1971). The total PEDro scores for these studies however were
low, ranging from 2 to 4 points. In addition, the effect of goal planning on patient motivation
was also investigated in four experimental studies conducted over short periods of time
(approximately one hour for each participant) (Gauggel & Billino, 2002; Gauggel & Fisher,
2001; Gauggel et al., 2002; Gauggel et al., 2001). These four studies mostly involved
populations of people with stroke or traumatic brain injury, were published by the same group
of authors, and achieved high total PEDro scores, ranging from 8-9 points. The combined
results from all these studies suggested that there is some limited evidence that goal planning
improves adherence to treatment regimes over the duration of a whole rehabilitation
programme and strong evidence that (for populations of people with acquired brain injury)
prescribed, specific, difficult goals result in better immediate performance on motor and
cognitive activities (see Table 5, p. 61-62 and Table 6, p. 63-64).
3.3.5 Effect of goal planning on self-regulation
Finally, a single study by Levine et al. (2000) investigated the effect of Goal
Management Training (GMT) on the rehabilitation of executive functioning following
traumatic brain injury. This study differed from the others included in this review because it
investigated the immediate effect of one approach to goal planning on an outcome (skills of
self-regulation of behaviour) that was secondary to the specified objective of the goal (i.e.
goal attainment). In an RCT involving 30 people with traumatic brain injury, this study
reported that a one hour session of GMT resulted in statistically significant improvements on
everyday paper-and-pencil tasks when compared to a control group receiving motor skills
training (Levine et al., 2000). With a total PEDro score of 4 however, this study offered only
low-quality evidence regarding the effectiveness of GMT.
60
TABLE 5: RCTs on the effect of goal planning on treatment adherence in rehabilitation programmes running for > 1 week
Reference Total n* Patient Population Aspect or approach to goal planning Main Results**
PEDro under investigation
Score
Bassett & 4 74 Patients with upper or Addition of either a) goals for No significant difference between the
Petrie (1999) (66) lower limb injury treatment being set collaboratively groups regarding: the self-reported number
receiving with the patient, or b) goals for of repetitions performed of each
physiotherapy treatment being mandated by the prescribed exercise or exercise sessions
physiotherapist versus c) no formally completed (except when post-hoc analysis
set goals. of arbitrarily selected subgroups was
performed).
Duncan & 4 16 Patients with heart Provision of a) prescribed goals for Patients with goals for exercise completed
Pozehl (2002, (13- failure undertaking frequency and duration of home significantly more exercise sessions,
2003) 14) home-based exercises exercises plus forms for patients to longer exercise sessions, and had greater
following the self-monitor their goal achievement adherence to prescribed exercise
completion of a versus b) no goals. frequency when compared to patients
supervised 12-week without goals (based on patients self-
exercise programme. reports).
Sperduto et 3 173 People with clinical Provision of a) prescribed behavioural Significantly more patients with
al. (1986) (not obesity undertaking a goals, modified at weekly meetings as behavioural goals completed the weight
reported)
weight loss participants progressed, as well as self- loss programme compared to those
programme monitoring forms and feedback versus without goals.
b) no prescribed goals.
** All between-group comparisons are statistically significant (p<0.05) unless otherwise stated.
CONTINUED OVER
61

Score
Howell 2 27 People receiving Provision of a) weekly collaborative The group involved in regular goal
(1986) (17- occupational therapy goal planning and evaluation versus planning was reported as having
22) for psychiatric b) weekly positive feedback. significantly greater ‘involvement’ with
disorders weekly therapy session (scored on a 5-point
scale by the occupational therapist) when
compared to the group without goals.
There was no significant difference
between the groups however regarding the
number of sessions attended.
62
TABLE 6: RCTs on the immediate effect of goal planning on patient behaviour, investigated over a short period of time (< 3 days)
Reference Total n* Patient Population Aspect or approach to goal planning Main Results**
Score
Gauggel et al. 9 109 Patients with brain Provision of a) a specific, difficult goal Specific, difficult goals resulted in
(2001) (109) injuries (n=62) or (a 20% improvement on baseline significantly better improvement in
orthopaedic injuries reaction time), with feedback on performance on the reaction time test
(n=47) undertaking a performance versus b) instructions to compared to instructions to ‘do your best’,
reaction time test. ‘do your best’, with no feedback on regardless of whether patients had
performance. orthopaedic or brain injuries.
Gauggel & 9 45 Patients with stroke or Provision of a) a specific, difficult goal Specific, difficult goals resulted in
Billino (45) traumatic brain injury (a 20% improvement on baseline significantly better improvements on the
(2002) undertaking the Purdue testing) versus b) instructions to ‘do Purdue Pegboard Test compared to
Pegboard Test. your best’. instruction to ‘do your best’.
Gauggel et al. 9 87 Patients with stroke or Provision of a) a specific, difficult goalAfter the provision of goals (trial 4),
(2002) (87) brain injury undertaking (a 20% improvement on baseline patient with specific, difficult goals made
six trials of a simple testing) versus b) a self-set goal of the significantly better improvements in
arithmetic task. patient’s choosing versus c) arithmetic performance compared to the
instructions to ‘do your best’. other two groups. This difference was no
longer significant however by trial 6.
There was no difference in performance
between patients who set their own goals
and patients instructed to ‘do your best’.
** All between-group comparisons are statistically significant (p<0.05) unless otherwise stated
CONTINUED OVER
63
Reference Total n Patient Population Aspect or approach to goal planning Main Result
Score
Gauggel & 7 69 Patients with acquired Provision of a) a specific, difficult goal Specific, difficult goals resulted in patients
Fischer (69) brain injury undertaking (a 20% improvement on baseline correctly calculating significantly more
(2001) six trials of simple testing) versus b) instruction to ‘do arithmetic equations compared to patients
arithmetic task. your best’. instructed to ‘do your best’.
Cross & 4 45 Orthopaedic patients Provision of a) education and Provision of prescribed goals resulted in
Parsons (45) receiving education prescribed goals for selection of no significant difference in the patient’s
(1971) provided by nurses on specific healthy food while in hospital, food selection behaviour for 3 days
healthy dietary b) education but no goals, and c) no following the establishment of the goals.
behaviour. education or goals.
64
3.4 Discussion
In 1979, Cytrynbaum and colleagues stated that goal planning was increasingly being
used as a therapeutic intervention to improve outcomes for patients, but identified that further
research was needed on which to base recommendations for the most effective approach to
goal planning in this regard (Cytrynbaum et al., 1979). It is interesting to note 27 years later,
despite the rhetoric around the importance of goal planning in rehabilitation, we have yet to
produce substantially better evidence. Despite positive findings regarding the effectiveness of
goals in some individual therapeutic contexts and some suggestion that goal planning can
influence patient motivation and treatment adherence, evidence regarding the generalisability
of goal planning to improve patient outcomes in rehabilitation is inconsistent at best.
One substantial barrier to the development of stronger conclusions regarding the

effectiveness of approaches to goal planning in rehabilitation is the extent of methodological
limitations of many studies. While some ideals of RCT design (such as blinding of patients
and therapists) are very difficult to meet when undertaking research on rehabilitation
inventions, a number of these limitations could have been addressed relatively easily. Future
studies into the effects of goal planning in rehabilitation should seriously attempt to include
the following in their method: concealment of randomisation and group allocation, adequate
measurement of severity of injury and baseline testing of performance on at least one outcome
measure, blinding of the outcome assessor, commitment to intention-to-treat analysis,
appropriate statistical analysis, and publication of the effect size and variability for all primary
outcomes. In addition to this, if researchers are intent on investigating the therapeutic effects
of different approaches to goal planning, consideration needs to be given to how these
approaches are manipulated as independent variables and how they are adequately controlled
for in comparison groups. A number of studies were excluded from the data synthesis phase
of this review because of inadequate management of goal planning as an independent
variable, making conclusions regarding the effect of goals in these studies of dubious value
(Glasgow et al., 1997; Glasgow & Toobert, 2000; Glasgow, Toobert, & Hampson, 1996;
Glasgow, Toobert, Hampson, & Noell, 1995; Glasgow, Toobert, Hampson, & Strycker, 2002;
Glasgow, Toobert, Mitchell, Donnelly, & Calder, 1989; Jeffery, Wing, & Mayer, 1998;
Rokke, Tomhave, & Jocic, 1999; Stenstrom, 1994; Stuifbergen, Becker, Timmerman, &
Kullberg, 2003). Some strategies for better management of goal planning as an independent
variable include: adequate description of what constitutes ‘usual practice’ regarding
65
rehabilitation planning and decision making, adequate description of how the approach to
goal planning under investigation differs from ‘usual practice’, and adequate control of
variables associated with the approach to goal planning (such as the amount of contact time
with health professions or any additional education and training provided alongside goal
planning). It is also important to avoid introducing additional variables to the ‘control’ group
(e.g. active encouragement to attend to other influences of behaviour, such as pain) without
also introducing these to the ‘goal planning’ group.
This review itself could also be criticised for having excluded studies not published in
peer-reviewed journals and for excluding non-randomised controlled trials. It is
acknowledged that including only published studies can introduce publication bias in a
review. Indeed, there is at least one RCT of goal planning effectiveness, reporting non-
significant findings, that has been published as a conference presentation only (Sewell, Singh,
Williams, Collier, & Morgan, 2001). However, given the already inconsistent findings in this
systematic review, the stance of limiting this review is arguably justifiable. It seems unlikely
that addition of further non-significant findings or findings from lower-quality design, non-
randomised studies would have substantially altered this review’s conclusions.
One final consideration requires referral back to the range of different purposes or
functions attributed to goal planning in rehabilitation. As well as improving patient outcomes
on standardised measures, goal planning is also thought to be a good framework for
evaluation of outcomes (i.e. to be used as the dependent rather than independent variable in an
RCT) for enhancing patient autonomy or ‘patient-centred’ therapy, and for demonstrating
accountability to contractual, legislative or professional standards. As discussed in Chapter 2,
synthesising evidence from studies using goal planning for fundamentally different reasons
would be misleading. The literature on using goal planning to enhance ‘patient-centred’
therapy for example is often based on philosophical arguments around the importance of
encouraging and supporting patient autonomy (Blackmer, 2000; Hass, 1993). Such belief
systems are not proved or disproved by quantitative methods such as RCTs. This review has
considered the current best-evidence regarding the therapeutic effectiveness of goal planning
in rehabilitation. Other types of evidence need to be considered when judging the value of
goal planning in rehabilitation towards different ends.
66
3.5 Conclusions
This systematic review has demonstrated that at present there is some limited evidence goal
planning can improve patients’ adherence to treatment regimes and strong evidence that
specific, difficult goals can improve immediate patient performance in some clinical contexts.
However, the evidence regarding any generalisable effect of goal planning on improving
outcomes following rehabilitation programmes is inconsistent at best.
These findings seem somewhat at odds with the high level of importance attributed to
goal planning in rehabilitation (as is described in Chapter 2). It would appear that the
perceived value of goal planning in rehabilitation has arisen from factors other than the
strength of evidence regarding its effectiveness for improving patient outcomes. Such
additional factors might include those that relate to reasons for goal planning other than
improving patient outcomes. Alternatively it is possible that the effectiveness of goal
planning in rehabilitation has been overestimated. Given this lack of consistent evidence
regarding the effectiveness of goal planning in rehabilitation and given the range of possible
interpretations regarding how and why goal planning should be applied, it seems that further
investigation into the way goal planning is used in actual clinical environments is warranted.
Inductive research methods, with the potential for generating fresh theoretical perspectives,
could be of benefit here for two reasons. Firstly, this type of research may provide
information about how the theories and concepts of goal planning are currently being applied
to the context of clinical rehabilitation (i.e. how current practice ‘fits’ with established
models) and, secondly, data from clinical practice could inform the future development of
such theories.
The following chapters describe the two grounded theory studies which attempt to
investigate the above questions concerning the application of goal planning in clinical
environments. In order to limit the scope of this investigation, the focus of these studies has
been placed on rehabilitation services provided for people with acquired brain injury. The
first study investigates this topic purely from the perspectives and experience of clinicians
working in such services. The second study incorporates data from interdisciplinary inpatient
settings. Prior to presentation of these studies however, an overview of constructivist
grounded theory (the research methodology that was employed) is required.
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4.1 Introduction
The next two chapters of this thesis describe two qualitative studies, which investigate,
in different ways, the application of goal planning in rehabilitation for people with acquired
brain injury. Grounded theory was selected as the research method of choice because it is an
approach suitable for studying actions and processes in a social context (Heath & Cowley,
2004; McCann & Clark, 2003a). Grounded theory has often been applied in order to expand
understanding and knowledge on topics where few theories currently exist. However, it has
also been recommended when researchers are seeking ‘fresh perspectives in familiar
situations’ (Stern, 1980, p. 226). Using grounded theory to study goal planning in
rehabilitation is an example of the latter.
A recent quantitative investigation of the use of research methods in published clinical

studies concluded that grounded theory is one of the two most commonly used approaches to
qualitative research – the other being phenomenology (McKibbon & Gadd, 2004). This
conclusion is somewhat misleading however, as there is more than one version of how
researchers can apply ‘grounded theory’ (Chiovitti & Piran, 2003). Furthermore, not all
researchers in the field agree on what is and what is not a ‘grounded theory’ approach to
research (Glaser, 2002). While all authors of texts on grounded theory methods have
described guidelines, rather than rules to its application (and have done so to allow the
method sufficient flexibility to be used creatively), there are a number of such ‘guidelines’
and considerable debate regarding the ‘correct’ way to undertake grounded theory (Hallberg,
2006). It has therefore been suggested that when reporting a grounded theory study,
researchers must clearly state whose guidelines they are following and how (Duchscher &
Morgan, 2004; Hallberg, 2006). Discussion of such issues is also important for any
consideration of the scientific rigour of a grounded theory study. The philosophical
assumptions and theoretical perspectives underlying a piece of qualitative research contribute
significantly to the justification for the use of particular methods, and thus should be referred
to when critically appraising such studies (Crotty, 1998; Madill, Jordan, & Shirley, 2000;
Mills, Bonner, & Frances, 2006).
This chapter therefore introduces the methodology of grounded theory; its origins and
development. Attention is paid here to some of the debate that has occurred around the
68
application of grounded theory in social science research. Much of the discussion in this
chapter relates to ontology, epistemology, theoretical perspectives and methodological
considerations. An explanation is provided at the end of this chapter on my own perspectives
regarding this debate, and a justification is given for the constructivist approach to grounded
theory taken in this thesis. Specific details regarding the methods used in the two subsequent
grounded theory studies are described at the beginning of Chapters 5 and 6.
4.2 Grounded theory methodology – origins and interpretations
4.2.1 The origins of grounded theory and development of discord
Grounded theory was first developed by Glaser and Strauss in the mid-1960s. Their
early work led to the publication of two books on death and dying and a textbook entitled The
Discovery of Grounded Theory, describing their new approach to research (Glaser & Strauss,
1967). Glaser and Strauss’s original work has been described as a reaction to the growing
dominance of quantitative methods in sociology at the time (Charmaz, 2006). Their work
challenged an existing assumption that qualitative research was ‘impressionistic, anecdotal,
unsystematic, and biased’ (Charmaz, 2006, p5). Glaser and Strauss’s initial textbook on
grounded theory offered a systematic method for collecting and analysing qualitative data –
one of the first publications to explicitly do so (Charmaz, 2006; Hallberg, 2006). Thus Glaser
and Strauss argued in favour of the legitimacy of qualitative research during a particularly
positivistic period in the history of sociology (Charmaz, 2006). Charmaz (1995) has stated
that Glaser and Strauss’s first text also challenged the division between theory and research,
the separation of data collection and data analysis, as well as ‘the assumption that qualitative
research only produced descriptive case-studies rather than theory development’ (Charmaz,
1995, p. 29).
Grounded theory arose from a convergence of two different research paradigms.

Glaser, from Columbia University, brought to grounded theory its rigorous and systematic
empirical methods, particularly those related to data codification and the systematic step-wise
progression from data to increasingly abstract concepts (Charmaz, 2006). Strauss, from the
University of Chicago, brought ethnographic traditions to grounded theory: those of field
research, the belief in subjective and social meaning, and the open-ended approach to data
69
collection and analysis (Charmaz, 2006). Importantly, Strauss also contributed to grounded
theory the theoretical perspective of symbolic interactionism. Symbolic interactionism is
derived from pragmatism (an American philosophical tradition) and ‘assumes that people
construct selves, society, and reality through interaction’ (Charmaz, 2006, p189). In symbolic
interactionism people are viewed as active agents in their own lives, who create and mediate
meanings in the world around them, rather than being simply passive actors subject to larger
social forces (Charmaz, 2006). Mead (1934), the American pragmatist who inspired symbolic
interactionism, and Blumer (1969), his student, who developed it and who first coined the
term were both influential sociologists from Strauss’s faculty in the University of Chicago.
Following the publication of their initial text on grounded theory however, Glaser and
Strauss parted ways and came to disagree over a number of fundamental aspects of grounded
theory research, at both philosophical and procedural levels (Heath & Cowley, 2004). Both
researchers came to write a number of texts, independent from one another, on the topic of
grounded theory method (Heath & Cowley, 2004). The philosophical differences between the
co-creators of grounded theory became public however in the early 1990’s when Strauss, now
having teamed up with Corbin, published Basics of Qualitative Research: Grounded Theory
Procedure and Techniques (Strauss & Corbin, 1990). Glaser responded with a textbook of
his own, Emergence vs Forcing: Basics of Grounded Theory Analysis (Glaser, 1992), in
which he roundly decried Strauss and Corbin’s representation of grounded theory and
described his failed attempt to block publication of their book. One of Glaser’s key
complaints was that Strauss and Corbin’s revision of grounded theory differed so substantially
from Glaser and Strauss’s original work (as Glaser viewed it) that Strauss and Corbin’s
approach was no longer ‘grounded theory’ and should not be labelled as such. Instead, Glaser
attempted to re-brand the Strauss and Corbin’s version of grounded theory as a new method
altogether, one that produced (in Glaser’s opinion) a ‘forced, preconceived, full conceptual
description’ (Glaser, 1992, p3) and not theory at all.
Since that time the debate regarding these and other methodological issues has not
abated, resulting in the production of different ‘schools’ of grounded theory (Duchscher &
Morgan, 2004; Heath & Cowley, 2004). Glaser’s texts have been described as the most
faithful to ‘traditional’ grounded theory (Heath & Cowley, 2004). Some scepticism of this
conclusion is warranted however, given that the strongest arguments in favour of it have been
espoused by Glaser himself (Glaser, 1992), placing greater importance on the more
70
positivistic aspects of the original method (such as the strict line-by-line reading of text, the
systematic division of codes into categories, and the determination of properties of categories)
over those aspects of grounded theory contributed by Strauss.
Other variants and adaptations of grounded theory have also arisen over time. For
instance, Mills, Bonner and Frances (2006) list publications that have taken grounded theory
into constructivist, feminist, critical theorist, and post-modern directions. While it is beyond
the scope of this chapter to analyse all these different interpretations of grounded theory, some
additional consideration of constructivist approaches to grounded theory is relevant to this
thesis. Notably, in recent years, Charmaz has consistently argued that grounded theory
methods can and should be used without researchers being required to subscribe to the post-
positivist assumptions of its co-creators (Charmaz, 2000, 2003, 2006). In particular, Charmaz
has argued in favour of constructivist grounded theory (which will be discussed in more detail
below).
Once again however, Glaser (2002) has strongly criticised such deviations from his
original texts, calling constructivist grounded theory a misnomer. In his rebuttal of
Charmaz’s work, Glaser (2002) suggested that the product of any constructivist approach to
qualitative data analysis can not be grounded theory, and is instead at best ‘descriptive
capture’ (para.11). Glaser’s (2002) perspective has been that ‘constructivism is an effort to…
avoid the work of confronting researcher bias’ (para.13), and he has quite baldly stated that
researchers and students who follow Charmaz’s approach to research do so because they are
limited in their ability to conceptualise (as opposed to simply describing) data (Glaser, 2002).
Clearly then, there is little clear agreement regarding the ‘correct’ way to undertake
grounded theory. To progress this discussion therefore, an attempt is made below to describe
in more detail some of the key similarities and difference between the various approaches to
grounded theory to date. Following this, an explanation and justification will be provided
regarding the philosophical and theoretical assumptions underlying the research methodology
adopted for this thesis.
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4.2.2 What is grounded theory?
Charmaz (2006) argues that historically there has been a lack of clarity in the use of the
term ‘grounded theory’, which can refer to both a) the methodology of the research process
and b) the product of that process. For the sake of clarity, in this chapter the term ‘grounded
theory’ is used specifically to refer to a methodology, unless otherwise stated. Even with this
distinction made, there is considerable variation in the interpretation of what comprises a
‘grounded theory’ study. Common to all grounded theory studies are methods used to
develop conceptual frameworks or theories from data through the use of systematic and
structured inductive analysis (Charmaz, 2006). Grounded theorists begin with data, which
they systematically raise to more conceptual levels, all the while ensuring that any developing
concepts or theories continue to have a strong foundation in the raw data (Charmaz, 2006;
Crotty, 1998; McCann & Clark, 2003a). Conceptual frameworks or theories developed using
this approach are thus said to be ‘grounded’ in the data (Charmaz, 2006). These inductive
methods can be contrasted with the deductive methods used to test theories (reduced to
hypotheses) common in quantitative studies (McCann & Clark, 2003a). They can also be
used to distinguish grounded theory from the process of theorisation in philosophical
speculation or pure logic, as these latter methods do not derive theory from, nor explicitly link
theory to, empirical data (Charmaz, 2006).
Traditionally, the aim of grounded theory research has been to produce ‘middle-range’
theories (Charmaz, 2006). Somewhat tautologically, middle-range theories have been
described as those which consist of ‘abstract renderings of specific social phenomena that
[are] grounded in data’ (Charmaz, 2006, p7) and that these differ from ‘grand’ theories, which
have ‘no [such] foundation in systemically analysed data’ (Charmaz, 2006, p7). Other
authors have suggested that grounded theory studies can result in one of two types of theories:
formal or substantive (McCann & Clark, 2003a; Strauss & Corbin, 1998). Most grounded
theories are substantive theories (Charmaz, 2006; Hallberg, 2006; McCann & Clark, 2003a),
in other words, theories that focus on specific social problems or processes within clearly
delimited contexts. Any grounded theory concerning the application of goal planning in
rehabilitation for people with acquired brain injury would be an example of a substantive
theory. Formal theories are considered to be more general than substantive theories, dealing
with broader conceptual topics (for example, pain experience) and may link several
substantive areas of enquiry (Charmaz, 2006; McCann & Clark, 2003a).
72
4.2.3 Common characteristics of grounded theory studies
Again, there are a number of perspectives on what might constitute the common
characteristics of any grounded theory study. McCann and Clark (2003a) listed seven key
characteristics that they claimed to be common to all grounded theory studies: 1) theoretical
sensitivity, 2) theoretical sampling, 3) constant comparative analysis, 4) coding and
categorising the data, 5) the use of theoretical memos and diagrams, 6) the use of literature as
a source of data, and 7) the integration of the theory. McCann and Clark (2003b) state that
‘where difference exists in these common characteristics, they relate mainly to the degree to
which any element is adopted, rather than the substance of the element’ (p22). Taking each of
these characteristics in turn then:
Theoretical sensitivity is the awareness that a researcher has when engaging in a

grounded theory study to the ‘subtleties of the data’ (McCann & Clark, 2003a, p10). It is
presumed that having such awareness gives the researcher the ability and insight to be
reflexive when viewing and analysing the data generated from their investigations (Strauss &
Corbin, 1998). The use of existing literature and prior knowledge on a research topic to gain
theoretical sensitivity is however something that has been hotly debated, as is discussed in
more detail below.
Theoretical sampling relates to the selection of research participants. Many qualitative

studies (not just grounded theory studies) initially employ ‘purposeful sampling’ to select
potential participants for investigation. In purposeful sampling, research participants are
selected on the basis of predetermined criteria usually derived from demographic
characteristics that the researcher wishes to see represented by the participants in their study
(Strauss & Corbin, 1998). In grounded theory however, as the study progresses, ‘theoretical
sampling’ is employed, whereby the researcher intentionally selects new participants (or new
sources of data) in order to explore, challenge or expand the evolving theory (McCann &
Clark, 2003a). Both purposeful and theoretical sampling are used to seek and explore
variation in the data on any given topic. Sampling in grounded theory is intended to continue
until ‘theoretical saturation’ (or ‘data saturation’) is reached, in other words until new data
reveals ‘no new direction, no new questions, and… no need to sample further’ (Morse &
Richards, 2002, p174). Hallberg (2006) however argues that the decision regarding when
theoretical saturation is reached is a subjective one (i.e. there is no external way of confirming
the achievement of theoretical saturation), therefore one could argue that it is not a good
73
criteria against which to evaluate whether a study has followed a grounded theory
methodology or not.
Constant comparative analysis involves the production of increasingly more abstract

concepts and theories from data through inductive processes of comparing data, categories
and concepts arising from the study (Charmaz, 2006). The constant comparative method of
grounded theory is iterative in that it occurs repetitively and cyclically throughout all stages of
the research, including data collection (via theoretical sampling), data analysis (through
coding and categorisation of the data) (McCann & Clark, 2003a) and, Charmaz would argue,
through the process of writing-up a study (Charmaz, 2006). The constant comparative
method is perhaps the most defining characteristic of grounded theory (Hallberg, 2006).
Coding data in grounded theory involves the process of ‘naming segments of data with
a label that simultaneously categorizes, summarizes, and accounts for each piece of data’
(Charmaz, 2006, p43). The coding and categorisation of data is the initial step in the analysis
of qualitative data and thus in the process of theory generation (Charmaz, 2006). As the
analysis progresses however, the codification of data takes on different forms. While Glaser
and Strauss differ in the way they present the various levels of data coding (Heath & Cowley,
2004), all grounded theory employs the use of more than one level of coding. Initially some
form of ‘open’, ‘substantive’ or ‘in-vivo’ coding is employed. This involves the direct coding
and categorisation of raw data. Following this, coding at a higher conceptual level is used,
whereby the emerging concepts from the initial coding are elevated to more abstract concepts
or categories (McCann & Clark, 2003a). McCann and Clark (2003a) state that for ‘an
emerging theory to be integrated, dense and saturated, a core category (or core variable) must
be present’ (p14). This core category is one which integrates and explains all other categories,
concepts and relationships in the data (McCann & Clark, 2003a).
The use of theoretical memos and diagrams relates to the researcher’s exploration and
manipulation of data, codes, categories and concepts in order to further the development of
the resultant theory (McCann & Clark, 2003a). Strauss and Corbin (1998) define memos as
‘written records of analysis that may vary in type and form’ (p217) and diagrams as ‘visual
devices that depict the relationships among concepts’ (p217). Memo-writing and
diagramming are considered essential techniques for researchers to remain engaged with their
74
data, for the abstraction of concepts beyond the purely descriptive, and for the practice of
reflective analysis (Charmaz, 2006; McCann & Clark, 2003a).
As suggested above, the use of literature as a source of data, while listed by McCann
and Clark (2003a) as a key component of grounded theory, is in fact an element around which
there is considerable debate (Heath & Cowley, 2004). As such, discussion of it has been left
to a later section in this chapter on differences in the application of grounded theory.
Finally, McCann and Clark (2003a) suggested that integration of the theory results from
the synthesis of all of the above techniques, assisted by three strategies: category reduction,
selective sampling of the literature, and selective sampling of the data. While others have
agreed that the integration of the theory is a key element of grounded theory, opinion differs
regarding the best way to achieve this (Charmaz, 2003).
Other authors have also suggested lists of key characteristics of grounded theory
studies, placing slightly different emphases on different components. Webb (2003) for
example has offered a provisional list of minimum criteria for any grounded theory study.
This list consisted of five components, four of which clearly overlap with those suggested by
McCann and Clark: 1) concurrent data collection and analysis, 2) theoretical sampling as part
of analysis, 3) identification of a core category grounded in the data, 4) first and second level
coding and 5) theoretical saturation (Webb, 2003). Furthermore, Webb (2003) stated that a
study cannot be considered a grounded theory study if all study data were collected prior to
any analysis (as mentioned above, they argued that data collection and data analysis should
occur concurrently) – this being a different research method (e.g. thematic analysis or content
analysis). Webb (2003) also stated that grounded theory cannot involve the ‘identification of
discrete themes with no linking core category’ (p545). However, she adds the rider that ‘a
study may not reach the final stage of fully developing an explanatory theory, but may
usefully inform [practice] by description and exploration’ (Webb, 2003, p545).
Yet another list of key characteristics of grounded theory has been offered by Hallberg
(2006), who suggested that the constant comparative method of analysis is the central
defining element of the grounded theory methodology. Hallberg (2006) lists nine essential
elements for grounded theory, reiterating most of the criteria described by McCann and Clark
(2003a) and by Webb (2003) above. Hallberg (2006) adds one additional characteristics to
these lists, that of ‘intensive interviewing’ (p143). It is questionable however whether
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‘intensive interviewing’ is particularly characteristic of grounded theory because it is a

technique for data collection that is common to many qualitative methodologies (Denzin &
Lincoln, 2000) and because interview data is not the only source of data applicable to
grounded theory (Glaser, 2002; Strauss & Corbin, 1998). In fact, Charmaz states: ‘Grounded
theory methods specify analytical strategies, not data collection methods’ (Charmaz, 2003,
p257). Indeed, grounded theory does not even require the collection of qualitative data, but
could equally be applied to quantitative data as well (Charmaz, 2003; Glaser, 2002).
4.2.4 Variation in interpretation and application of grounded theory
Some authors (including Glaser himself) have suggested that Glaser and Strauss’s
different perspectives on grounded theory always existed. It was just that these difference
only become apparent on the publication of their separate texts in the early 1990’s (Glaser,
1992; Heath & Cowley, 2004; McCann & Clark, 2003b). A full account of the differences
between Glaser’s and Strauss’s approaches to grounded theory (let alone those of more
contemporary theoreticians) is outside the scope of this thesis. However, a brief overview of
some of the key areas of difference, relevant to this thesis, is provided below.
4.2.4.1 Differences in ontology, epistemology, and theoretical perspective
While Glaser and Strauss (and other grounded theorists) have clearly held different
philosophical views, there are two reasons why full analysis of these differences is difficult.
The first is that Glaser and Strauss never quite appeared to make their own viewpoints on
such issues explicitly clear: scholars of grounded theory have been required to make
assumptions about what Glaser and Strauss’s philosophical leanings have been (Hallberg,
2006; Lomborg & Kirkevold, 2003). The second difficulty is that authors of papers analysing
such differences appear, not infrequently, to confuse the terms ‘ontology’, ‘epistemology’,
and ‘theoretical perspective’. Thus, McCann and Clark (2003b), describe Strauss and
Corbin’s approach to grounded theory as having a ‘social constructivist ontology’ (p23) in
comparison to Glaser’s ‘critical realist ontology’ (p23) (when ‘social constructivism’ is in fact
an epistemology, not an ontology). Similarly, Madill, Jordan, and Shirely (2000) lump
realism, contextual constructionism, and radical constructionism together as alternative
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epistemologies that could be applied to grounded theory (when in fact only the last two are
epistemology; the first is again an ontology.) Despite these difficulties, clarification of such
issues is important as it explains much of the variation in the process of grounded theory
recommended by various authors.
At risk of belabouring a point, clarification of terminology is required here: Ontology is

the study of being and existence. It relates to how one perceives the nature and structure of
reality, and in social science, the nature and structure of social reality (Crotty, 1998).
Epistemology is the study of knowledge. It relates to one’s beliefs regarding the nature of
knowledge and how it is possible to know what we know (Crotty, 1998). A theoretical
perspective is ‘the philosophical stance lying behind a methodology... [which provides] a
context for the process involved and a basis for its logic and its criteria’ (Crotty, 1998, p66).
While, a research methodology (for completeness) is the research strategy that is employed in
a study; not to be confused with research methods, which are the specific techniques used for
conducting a study, including methods of data collection and analysis (Crotty, 1998).
In grounded theory then, it would appear that regardless of their other differences,
Glaser and Strauss have shared an ontological perspective, that of critical realism (Mills,
Bonner, & Francis, 2006). Critical realism assumes an objective reality exists, but that this
reality can only ever be imperfectly perceived (Mills et al., 2006). Glaser and Strauss also
appeared to have shared a broadly post-positivist theoretical perspective informed by an
objectivist epistemology, although Glaser has leant more heavily towards positivism and its
epistemological base of objectivism (Charmaz, 2000).
‘Objectivism’, wrote Crotty (1998), ‘is the epistemological view that things exist as
meaningful entities independently of consciousness and experience, that they have truth and
meaning residing in them as objects’ (p5). Positivism, the theoretical perspective, asserts that
the job of science is to discover the objective things in reality and their nature (Crotty, 1998).
The positivist belief assumes there is constant scientific progress towards absolute and certain
understanding about the ‘real’ world (Crotty, 1998). Post-positivism, while remaining faithful
to the epistemology of objectivism, questions ‘the absoluteness and dogmatism of positivist
science’ (Crotty, 1998, p29), including the capacity to make unambiguous observations of the
‘real’ world.
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Thus, Glaser has asserted a belief that data has a ‘true nature’ (Glaser, 1992, p4), (a
critical realist ontology), and that it is the job of the grounded theorist to discover this true
nature ‘as objective as humanly possible’ (Glaser, 2002, para.23), (a post-positivist theoretical
perspective). Similarly Corbin and Strauss appeared to hold a belief in the existence of a
‘real’, but imperfectly understood, social reality and post-positivist theoretical perspective,
writing that: ‘True, only God can tell infallible (sic) humans the “real” nature of reality…
human grasp of reality never can be that of God’s, but hopefully research moves us
increasingly towards a greater understanding of how the world works’ (Strauss & Corbin,
1998, p4).
Glaser’s commitment to objectivism and post-positivism has been consistent and at

times assertively stated. Glaser (1992, 2002) has held an unshakeable faith in the existence of
truths in social science data, and in the ability of grounded theory to discover them (within the
limits of human fallibility). Glaser (1992) views the researcher as a neutral observer of the
social world, assisted in this process through the methods of grounded theory. Where bias
exists in scientific observation, Glaser (2002) has stated that ‘the constant comparative
process reveals these biases… [thus] the abstractions that emerge become independent of the
research bias’ (para.16).
Strauss and Corbin appear to be a little more difficult to pin down regarding their
philosophical perspectives on grounded theory. Some authors have stated that Strauss and
Corbin’s approach to grounded theory has drawn on epistemological foundations and
theoretical perspectives other than objectivism and post-positivism, including: social
constructivism, poststructuralist, postmodernism, relativism (an ontological perspective)
and/or subjectivism (Annells, 1997; Madill, Jordan, & Shirley, 2000; McCann & Clark,
2003b). These assumptions may have arisen in part from claims by Strauss and Corbin
(1998) such as that ‘analysis is the interplay between researchers and data’ (p13). Charmaz
(2003) however has pointed to Strauss and Corbin’s emphasis on ‘an objective external
reality… unbiased data collection… a set of technical procedures… verification [methods]…
[and] giving voice to their respondents, representing them as accurately as possible’ (p250),
and she has thus stated that while Strauss and Corbin may have some leanings away from
positivism and objectivism, the main body of their work still lies firmly in that camp.
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Charmaz (2006) has offered a clearer picture of what a constructivist approach to

grounded theory should look like. Constructivism, Charmaz has explained, is based on an
assumption that ‘people, including researchers, construct the realities in which they
participate’ (p187). In constructivism, ‘meaning’ is not presumed to reside in objects (as it is
in objectivism), but is created by the interaction of conscious beings with them (Crotty, 1998).
Frequently, constructivism is associated with a relativist ontology, where by the existence of
multiple social realities is assumed (Crotty, 1998). Charmaz (2003) has argued that rather
than being a neutral observer, and discoverer of social truths, the constructivist co-creates
grounded theory with the research participants. While, Charmaz’s (2003) constructivist
grounded theory is still aimed towards understanding the participants’ world and towards
developing theory from research data (rather than imposing preconceptions on that data), the
emphasis here is instead on ‘interpretive understanding’ (p250) rather than unbiased reporting
of ‘real world’ social processes. The constructivist researcher is thus not considered
independent from that which is researched. Instead, data, Charmaz (2003) has declared ‘are
narrative constructions’ (p258).
Glaser (2002), in particular, has taken significant exception to this view of grounded
theory, as noted above. One of Glaser’s (2002) key criticisms, from his positivistic
perspective, has been that this constructivist approach distorts grounded theory methodology
and hampers the emergence of the ‘true’ nature of the data. Glaser has asserted: ‘Conceptual
reality DOES EXIST [his emphasis]’ (para.40), and that a constructivist approach to grounded
theory has ‘destroyed all notions of accuracy, or posit a reality as truly nonexistent, but just a
figment of the mind’ (para.40). This view however confuses a constructivist epistemology
with subjectivism. In subjectivism ‘meaning’ is assumed to be imposed on objects by the
subject (e.g. the researcher), rather than being constructed through the interaction between the
subject and the object. It is frequently associated with the theoretical perspective of post-
modernism. According to Crotty (1998), this is a common misinterpretation of constructivist
epistemology, even among those claiming to follow a constructivist epistemology. Crotty
(1998) asserted that constructivists believe people create meaning from objects in the world:
they do not create meaning from nothing. Thus, constructivists are intensely focused on
objects in the real world (and their relationship to them); not on the introspective workings of
their own minds.
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4.2.4.2 Differences regarding the role of the researcher in the production of the study
Related to epistemological assumptions and theoretical perspectives are beliefs

regarding the role of the researcher in the production of the research. Glaser’s position is
quite clear: the researcher should be as independent as possible from that which is researched
– the neutral observer (Glaser, 1992; Glaser, 1994; Glaser, 2002). Glaser (2002) has stressed
the need for the researcher to interfere as little as possible with the production of the data,
stating that interviews, when used as a data collection method, should involve mostly ‘very
passive listening’ (para.6). Furthermore, the focus of data analysis, Glaser (2002) has stated,
should be on those issues which are of most importance to the research participants. On the
topic of interpretation of data, Glaser (2002) stated: ‘When I say that some data is interpreted,
I mean the participant not only tells what is going on, but tells the researcher how to view it
correctly – his/her way. I do not mean that they are mutually built up interpretations. Adding
his or her interpretations would be an unwarranted intrusion of the researcher’ (para.10). In
other words, according to Glaser, research participants interpret their world: grounded
theorists (when engaging in analysis) do not. In Glaser’s (1992) view, the researcher must
patiently wait for the grounded theory to ‘emerge’ from data, rather than to ‘force’ a theory on
that data through preconceived categorisation, questioning, or hypothesising.
In Strauss and Corbin’s (1998) version of grounded theory, the researcher is considered
to take a more active role in the process of analysis. Strauss and Corbin (1998) have referred
to ‘the interplay that takes place between data and researcher in both gathering and analyzing
data’ (p58), stating that: ‘This interplay, by its very nature, is not entirely objective as some
researchers might wish us to believe’ (p58). With reference to this interplay, Strauss and
Corbin (1998) have suggested the use of multiple analytical techniques such as the use of
dimentionalisation, questioning, ‘the flip-flop technique’ (p94-95), and use of
conditional/consequential matrices.
While not necessarily subscribing to all of Strauss and Corbin’s analytical techniques,
Charmaz (2003) has taken an interpretative approach to grounded theory further, stating more
explicitly that the researcher does not merely observe the data, but creates the data and the
resultant analysis through their interaction with the object of their research (including, of
course, their interaction with any research participant). The researcher, according to Charmaz
(2003), does not discover a theory grounded in their data, but actively constructs it. From her
constructivist perspective, Charmaz (2003) has also emphasised a need for the researcher to
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develop an intimate familiarity with the research participants, suggesting that one interview is
insufficient to build such a relationship and risks the analysis becoming incomplete or
representing a ‘sanitized view of experience’ (p275).
4.2.4.3 Difference regarding the place of induction, deduction and verification
Authors of various approaches to grounded theory have also disagreed over the place of
induction, deduction, and verification during data analysis. Glaser (1992) has asserted that
grounded theory methods must focus solely on inductive analysis; on the emergence of theory
from data. Corbin and Strauss however have introduced deductive methods to grounded
theory, stating that during the process of constant comparison the researcher will develop
hypotheses, which they can then test by selectively sampling further data. ‘Interpretation’,
Corbin and Strauss (1998) have suggested ‘is a form of deduction’ (p136). However, they
have also added the rider that any such deductions must be followed by validation, again
through constant comparison analysis, to ensure that theory still emerges from the data.
Corbin and Strauss have at times appeared to align such processes of deduction and validation
with the verification of the emerging theory (Heath & Cowley, 2004). Glaser (1992) has been
adamant that grounded theory is not a verificational method, and that verification should be
left to the standardised methods of quantitative science. Interestingly, Charmaz (2006) has
concurred with Glaser on this point, but has preferred the term ‘plausible accounts’ (p132)
when referring to grounded theories rather than that of verified knowledge.
4.2.4.4 Difference regarding the use of literature and/or prior knowledge
The various schools of grounded theory also differ in their recommendations regarding
how and when researchers should seek and/or use prior knowledge on their topic of inquiry.
Examples of such prior knowledge might include previous clinical training, beliefs or
perspectives, but also includes any background reading of the literature. This debate relates to
the topic of ‘theoretical sensitivity’ in grounded theory. Glaser (1992) has asserted that when
initiating a new project, researchers should actively avoid any review of the literature in the
substantive area under investigation. Any such pre-reading, according to Glaser (1992), could
contaminate the analysis. Instead, Glaser (1992) has championed the idea that researchers
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must ‘learn not to know’ (p24), stating that this is crucial to gaining theoretical sensitivity.
The grounded theorist, wrote Glaser (1992), should enter the field with ‘abstract wonderment’
(p22). Glaser (2002) has allowed researchers to include data from their own personal
experience, but stated that these experiences should be treated as supplemental data only (i.e.
converted into transcripts and coded like all other data in the study) and not privileged in the
analysis in anyway. Glaser (1992) however does direct researcher towards literature reviews
on completion of their study in order to support their findings.
Corbin and Strauss (1998) however have taken the contrary view that pre-reading of the
literature around a topic and reflection on prior knowledge can help enhance theoretical
sensitivity and even generate hypotheses for investigation during data analysis. For example,
Corbin and Strauss (1998) have stated that it is appropriate to undertake pre-reading of the
literature before beginning data collection as a means of generating initial questions or topics
for discussion with interview participants, or for the generation of initial codes and concepts
from the data. Charmaz (2006) has taken a similar position to that of Corbin and Strauss, but
has stated that ‘preconceived theoretical concepts may provide starting points for looking at
your data but they do not offer automatic codes for analyzing these data’ (p68). Like Glaser,
Charmaz (2006) has argued that all codes must earn their way into the analysis, through
inductive processes and the constant comparative method.
4.2.4.5 Differences regarding the selection of the research problem
Following on from the above, Glaser (1992) has asserted that the researcher may enter
the field with an area for investigation, but cannot come to a study with a specific pre-
established research problem. Again, from Glaser’s (1992) perspective this would amount to
imposing description on the data rather than allowing concepts to emerge from the data.
Instead, Glaser (1992) has argued that the research problem emerges during the study and that
it should centre on only the main concerns of the research participants. In contrast, Corbin
and Strauss (1998) (and Charmaz, 2006, from her constructivist perspective), have argued that
initial research problems may arise from personal experience, suggestions by others, analysis
of the literature as well as from the study itself.
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4.2.4.6 Differences regarding the focus of inquiry
It is also worth noting, that these different approaches to grounded theory seem geared
towards different areas of scientific inquiry. Given Glaser’s intense focus on participants’
unadulterated perspectives, Glaser’s version of grounded theory seems best suited for studies
of the phenomenological; on the views and perspectives of participants regarding basic social
process in the context of their lived world (McCann & Clark, 2003b).
It has been suggested that in comparison to Glaser, Strauss and Corbin have broadened
their focus of their methodology to include an additional emphasis on ‘macro’ influences in
the participants’ world (McCann & Clark, 2003b). This includes analysis of the cultural
milieu and its influence on participants’ perspectives or experiences (McCann & Clark,
2003b). Therefore, Strauss and Corbin’s (1998) approach to grounded theory seems better
suited to analysis of social processes within complex group environments.
Similarly, Charmaz (2003) has highlighted risks associated with focusing solely on the
voiced opinions of research participants, stating that what participants assume or are not
aware of may be much more important than what they explicitly discuss in interview settings.
Furthermore, Charmaz (2000) has argued: ‘An acontextual reliance on respondents’ overt
concerns can lead to narrow research problems, limited data, and trivial analyses’ (p. 514) –
an opinion that Glaser (2002) has adamantly rejected.
4.2.4.7 Differences regarding the constitution of a theory
Charmaz (2006) has suggested that a positivist perspective on what constitutes a theory
differs from an interpretative one. Positivist perspectives, Charmaz (2006) argued (and here
she has included Strauss and Corbin as well as Glaser) focus on explanation and prediction.
Positivist theory strives for generalisation and parsimony, treats concepts as variable, and
generates hypotheses for testing. Alternatively, Charmaz (2006) has offered an interpretative
definition of theory, which she stated, ‘emphasizes understanding rather than explanation’
(p126). In comparison to the reductionist explanation of positivist theory, interpretative
theory ‘calls for imaginative understanding of the study’s phenomenon’ (Charmaz, 2006,
p126) and requires the acceptance of indeterminacy, multiple realities, and a belief in ‘facts’
being value-laden (Charmaz, 2006).
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4.2.4.8 Differences regarding evaluation of grounded theory
Given the different recommendations that have existed in the application of grounded
theory and its underlying philosophical assumptions, various authors have (understandably)
advocated slightly different methods in the evaluation of grounded theory studies. Originally,
Glaser and Strauss (1967) introduced the criteria of fit, work, relevance and modifiability for
judging the quality of grounded theory studies. This is an approach that Glaser (1992)
continued to champion in his later texts. Fit referred to the degree to which the categories in a
grounded theory study emerge from the data rather than from some pre-established theory or
other source (Lomborg & Kirkevold, 2003). Work related to the explanatory power of a
study; its ability to explain or predict observation with respect to the theory (Lomborg &
Kirkevold, 2003). The relevance of a theory was analysed by examining its significance in
terms of actions and processes in the area of study (Lomborg & Kirkevold, 2003) – (from
Glaser’s (1992) perspective, this meant the degree to which the emergent core theme matched
the issues of most importance to the research participants). Lastly, the modifiability of a
theory referred to the capacity that it had to change to accommodate new data if such data
were to later emerge. Lomborg & Kirkevold (2003) noted that these criteria were all
interrelated, with the notion of ‘fit’ forming the basis for the other three criteria. Lomborg &
Kirkevold (2003) have also suggested that interpretation of whether or not a theory has a good
‘fit’ with its empirical data is dependant in part on the underlying beliefs regarding ontology
and epistemology (as described above). Thus a positivist with a realist ontology would
presume that fit referred to the degree to which a theory corresponded with reality from an
objective point of view, whereas a constructivist from a relativist perspective would be
interested in the plausible correspondence between the theory and social constructions of
reality.
In comparison, Strauss and Corbin (1998) have been less concise regarding their
recommended approach to the evaluation of a grounded theory study. They advocate the four
criteria for evaluating a theory described above, but added several more criteria to these.
Some of these, they have suggested, are the common criteria for evaluation of any qualitative
research (Strauss & Corbin, 1998). These particular criteria relate to the reliability, credibility
and validity of the research data, and are based on traditional tenets from quantitative science,
modified for a qualitative context (Strauss & Corbin, 1998). In addition to these, Strauss and
Corbin (1998) have added seven criteria for evaluation of the research process and a further
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eight criteria for the evaluation of the empirical grounding of the study. Strangely, the
framework for consideration of all these criteria advocated by Strauss and Corbin (1998) seem
a little incomplete, with a number of overlaps (and possible contradictions) between ‘new’
and ‘old’ criteria. For example, the whole concept of evaluating the empirical grounding of
the study appears to expand on the concept of evaluating the fit between a theory and its
underlying data, although it is not described as such by Corbin and Strauss (1998). The
seventh criterion for evaluation of empirical grounding is stated as being: ‘Do the theoretical
findings seem significant, and to what extent?’ This clearly overlaps with (or perhaps is
intended to replace) the concept of the ‘relevance’ of a theory, although again it is not stated
as such. Furthermore, some of the additional criteria seems to lack justification. For
example, the eighth criterion, that ‘the theory stand[s] the test of time and become[s] part of
the discussions and ideas exchanged among relevant social and professional groups’ (p272), –
seems to imply a grounded theory study could be meaningfully evaluated on the basis of its
popularity. However in their description of this eighth criteria, Corbin and Strauss (1998)
referred to a good theory being able to withstand continued testing over time – a concept not
dissimilar to that of ‘modifiability’ in the original Glaser and Strauss (1967) text.
Charmaz’s (2006) approach to evaluation of grounded theory was perhaps more similar
to that of Glaser and Strauss (1967) than to Corbin and Strauss (1998) multi-variable
approach. Charmaz (2006) included Glaser and Strauss’s (1967) first four criteria (fit, work,
relevance and modifiability) for evaluating the relationship between the emergent theory and
its underlying data, but to this she added a further four criteria to evaluate, what she has called
disciplinary, evidentiary or aesthetic issues, namely: credibility, originality, resonance and
usefulness (Charmaz, 2006). Credibility refers to how believable the research process, data
analysis and breadth of the final theory is (Charmaz, 2006). Originality refers to how novel
the resultant work is – whether it produces new perspectives or whether it is a re-packaging of
pre-established concepts (Charmaz, 2006). Resonance relates to the degree with which a study
is meaningful to people or situations outside the immediate scope of the lives of the individual
people who participated in the research, while usefulness describes the utility of the analysis
and its interpretations – its applicability to further research or other non-scientific contexts
(Charmaz, 2006). While reproducing some of the new criterion suggested by Corbin and
Strauss (1998), Charmaz’s (2006) additional criteria appear to be better developed and more
succinct, as well as clearly matching her constructivist epistemological stance.
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4.3 Justification for the approach taken in this thesis
When selecting an approach to research, the choice of research methods and

methodology should be driven largely by the research question (or area of study) rather than
vice versa (Crotty, 1998). In this thesis, the focus of investigation was on the application of
goal planning in interdisciplinary rehabilitation settings for people with acquired brain injury.
Here, I assumed that interdisciplinary rehabilitation occurs within a complex social
environment, with multiple stakeholders who do not necessarily share similar views about
what goal planning is or how it should be applied. Stakeholders in rehabilitation might
include the patients; their family, carers and supporters; the various nurses, allied health
professionals, doctors and other clinicians; as well as the funders of the rehabilitation services
and other related organisations. I also assumed that it was possible for the application of goal
planning to be influenced by organisational or institutional factors (such as organisation or
governmental policies and procedures) in addition to factors that might arise from the
involvement of individual stakeholders. In other words, the aim of this research was not to
develop a grounded theory about the shared perspectives of only one relatively homogenous
group (e.g. patients with similar levels of disability), but rather to attempt to progress the
development of theory regarding the way goal planning occurs within the whole system of
interdisciplinary rehabilitation. Nor did I intend for this thesis to be purely a study of the
phenomenological. Therefore, Glaser’s (1992) approach to grounded theory, with its
emphasis on uncovering the primary concerns of interview participants, was unlikely to result
in the breadth of understanding that was the objective of my work.
In addition to this, my own personal beliefs regarding the nature of reality and the
acquisition of knowledge also influenced my choice of research approach. I simply did not
find an objectivistic perspective on data arising from this thesis to be plausible. It seemed
impossible, to me, to follow Glaser’s (2002) recommendations about avoiding the intrusion of
my own views on the study data. It seemed equally impossible that abstractions about goal
planning could just emerge from the data, as suggested by Glaser (2002), without any
interpretative influence. The very concept of goal-oriented human performance itself seemed
to be potentially culturally loaded*, so to presume that one could analyse the study data
*
For example, while the exact origins of the ‘SMART’ acronym (so popular in many rehabilitation
organisations) appears to have been lost, it is most often attributed to motivational speakers from North America
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without being influenced by any prior beliefs on the topic seemed particularly artificial.
Furthermore, given my previous reading on the topic, it seemed presumptive to assume that
there might be only one ‘correct’ version of reality regarding the use of goal planning in
rehabilitation, even if goal planning was considered from the perspective of a single clinical
case. I therefore approached this thesis from a relativist ontological perspective and a
constructivist epistemology.
These philosophical dispositions further influenced my selection of methodology and

method. Regarding the use of existing literature on the substantive topic under investigation
(e.g. that which is presented in the first three chapters of this thesis), I assumed that such
background information would only strengthen my theoretical sensitivity to the area of study
when entering the field. In fact, one of the unique aspects of this research topic was that some
research participants (within the clinician population) could have read this background
literature themselves. Therefore, extensive knowledge of this literature seemed necessary to
fully understand the points of view I might potentially encounter among those interviewed.
While Glaser’s (1992) dictum that researchers should ‘learn not to know’ (p24) might have
some poetical aesthetic, it is also for all practical purposes a paradox. Learning, by definition,
is the cognitive process of acquiring knowledge. The real intent of Glaser’s dictum perhaps
was that researchers should avoid allowing prior knowledge to influence the induction of
theory from data. However, he has taken this a step further by stating that best way to avoid
this imposition on analysis is by avoiding acquisition of additional knowledge altogether,
prior to undertaking the study (Glaser, 2002). Charmaz’s (2006) perspective seemed better
suited to the aims of this thesis, namely that prior reading of the literature could assist with
gaining theoretical sensitivity to study data, but only as a way of looking at the data; not as a
means of generating automatic codes for analysis of the data. Again, this perspective added
support for a constructivist approach to the study methodology.
My constructivist leanings also influence my methods for data collection. In interviews,

I attempted to actively engage with participants, building rapport with them to construct my
during the late 1980’s and early 1990’s (such as Stephen Covey and Zig Ziglar), who promoted the belief that
you must have goals in order to achieve anything in life. This is a philosophy however which is not universally
accepted. In Zen Bhuddism, for instance, making conscious effort towards achieving a goal is seen as a potential
barrier to self-fulfilment (Herrigel, 1953).
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data, rather than, as Glaser (2002) suggested, minimising my involvement in these

conversations to mostly passive listening. This applied particularly to the second of my two
grounded theory studies. In this second study I collected data from multiple sources (from
written documents, from audio-recording of team meetings, and from interviews etc.) and
over a period of time (following individual patients through their course of inpatient
rehabilitation and on into the community). Here, because of the nature of this method, I was
able to invite the research participants to reflect on earlier data related to individual cases. For
example, I was able to ask their perspectives on specific events I had observed or on specific
goals that had been documented. I also was able to interview key participants on multiple
occasions, building further rapport with them over time, as has been recommended by
Charmaz (2006).
Finally, in my write up of this thesis, I have been careful to avoid silent authorship,
which Charmaz (2006) has suggested implies pretensions about neutrality and objectivity that
are not compatible with a constructivist approach to grounded theory. I have consciously
used first person in order to present clearly, where relevant, my contribution to the
construction of this research and the data arising from it. Thus the constructivist approach to
grounded theory has influenced all aspects of this thesis.
4.4 Conclusion
Grounded theory is an inductive research methodology designed for investigating
actions and processes in a social context. It is therefore ideally suited for research into the
application of goal planning within the system of interdisciplinary rehabilitation. There are a
number of different perspectives regarding how grounded theory should be applied. Opinions
about the ‘right’ approach are based to a large degree on philosophical assumptions regarding
the nature and structure of social reality, as well as beliefs regarding the appropriate process
for generating scientific knowledge. The methods of grounded theory underpinning the
research in this thesis have followed a relativist ontology and constructivist epistemology, as
has been championed by Charmaz (2000, 2003, 2006).
The following chapters describe two grounded theory studies. Chapter 5 presents the
construction of grounded theory regarding how clinicians talk about the application of goal
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planning in the rehabilitation of people with acquired brain injury. Chapter 6 takes the data
collection and analysis into the field of inpatient rehabilitation for people with stroke. In this
second study, data is gathered from multiple sources (field notes, clinical files, audio-recorded
interactions between clinicians, patients, and family members as well as interviews with these
stakeholders) around a series of single clinical cases. Grounded theory methods are used to
construct a framework for viewing the application of goal planning in the context of inpatient
rehabilitation for people with acute stroke. Broadly speaking, Chapter 5 focuses on what
clinicians say about goal planning, while Chapter 6 includes what they (and other
stakeholders in the rehabilitation) do when it comes to applying goal planning in
rehabilitation for people with brain injury.
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Chapter 5: How clinicians talk about goal planning for people with brain injury
Chapter 5: How clinicians talk about the application of goal

planning to rehabilitation for people with acquired brain injury
5.1 Introduction
This chapter describes a study in which I used grounded theory methods in order to
investigate clinicians’ perspectives on goal planning in interdisciplinary rehabilitation for
people with brain injury. To date, a number of qualitative investigations have been published
examining the application of goal planning to specific areas of clinical rehabilitation
(Conneeley, 2004; Holliday, Ballinger, & Playford, 2007; Lawler et al., 1999; McColl,
Paterson, Davies, Doubt, & Law, 2000; Melville et al., 2002; Parry, 2004; Playford et al.,
2000; Schulman-Green, Naik, Bradley, McCorkle, & Bogardus, 2006; Wottrich, Stenstrom,
Engard, Tham, & Von Koch, 2004; Wressle et al., 2003; Wressle, Öberg, & Henriksson,
1999). Many of these were published either during or after the completion of the study that is
reported in this chapter. Nevertheless, these papers should be considered prior to presenting
this study. Broadly speaking, this literature has identified that: a) goal planning in the context
of clinical rehabilitation does not always appear to occur in the manner that is recommended
in the literature, and b) there are factors in the context of clinical rehabilitation that act as
barriers to (or conflict with) achievement of goal planning ideals.
Playford et al. (2000) for instance reported the results from a workshop on goal
planning, involving 16 health professionals from a variety of inpatient and community teams.
They identified that these teams employed at least four approaches to goal planning, which
differed in terms of the process used to set goals and the recommended content of goals.
These approaches related in part to perceived needs of the local clinical contexts. Playford et
al. (2000) also identified several difficulties with goal planning. Formal goal planning was
viewed as something that was a foreign activity for many patients, so patients did not always
respond in a way that health professionals might prefer. Goal planning with patients was
described as requiring intimate knowledge of patients’ lives and social environments, but that
development of this knowledge needed more time than was often available in the clinical
setting. The clinicians in this study also reported having difficulty with involving patients
who had communication impairments and that there was a tendency for teams not to
acknowledge the more challenging goals raised by patients. These factors, combined with a
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suspicion that patients simply concurred with the opinion of health professions, meant that
goals were not always negotiated with patients to the extent that the authors felt was ideally
preferred. In addition, goal planning in hospital contexts was viewed as being insensitive to
the roles and needs of people in their communities, and concerns were expressed that the
practice of goal planning was limited by organisational issues such as staff turnover and
patient length of stay (Playford et al., 2000).
Recently Holliday, Ballinger, & Playford (2007) conducted a follow up study, using
focus group methods in order to examine the perspectives of patients on goal planning in the
context of neurological rehabilitation. This study reported that patients understood goal
planning in a range of different ways, and that their involvement in goal planning was
moderated by a number of factors such as their prior experience of goal planning in non-
health contexts, their assumptions about rehabilitation, and the characteristics of their disease
process; in particular whether they had a degenerative condition or not (Holliday et al. 2007).
Interestingly, some of the study participants did not attribute that same degree of importance
to goal planning as did the authors of this paper; with these participants suggesting that goal
planning had little bearing on their recovery from illness and disability (Holliday, Ballinger et
al., 2007). Holliday et al. (2007) interpreted this to mean that these participants had not been
adequately informed about what goal planning in rehabilitation involved. However, given the
lack of robust evidence in favour of the efficacy of goal planning (c.f. Chapter 3), this
perspective could be debated. Holliday et al. (2007) also concluded that a ‘keyworker’ role
facilitated greater patient involvement in, and understanding of, the goal planning process.
Another qualitative study into the application of goal planning in rehabilitation has been
reported by Conneeley (2004). Using phenomenological methods, Conneeley (2004) studied
the experiences of patients, their family and health professionals regarding a newly introduced
process for goal planning in her own rehabilitation unit. Conneeley (2004) reported that in
general, patients felt the goal planning process was empowering and motivating, and that this
tended to increase their confidence during rehabilitation. The staff were reported as believing
that the rehabilitation process had become more ‘patient-focused’ (Conneeley, 2004, p252)
after the introduction of goal planning, but a number of ongoing challenges were also
identified. Like Playford et al. (2000), the health professionals in Conneeley’s (2004) study
identified that goal planning was difficult when patients had severe cognitive or
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communicative disorders and that the relationship between hospital-based goals and
community-focused goals was not always clear. Conneeley (2004) also identified that
involving patients in goal planning was particularly difficult at the beginning of a
rehabilitation episode because patients were seen to lack knowledge relevant to their clinical
situation and to the team’s process of goal planning. As a result they tended to be viewed as
lacking insight and lacking the ability to set ‘realistic’ goals. Consequently the goal planning
was reported as being somewhat necessarily more ‘therapist led [than] patient led’
(Conneeley, 2004, p253).
A fourth qualitative investigation of goal planning in a team context, involving

interviews with 30 health professionals and patients, was reported by Wressle et al. (1999).
These authors concluded that, within the context of their study, patients did not participate
effectively in the goal planning process and that the resulting goals tended to be ‘vaguely’
stated (Wressle, Öberg, & Henriksson, 1999). It was noted that due to financial pressures
(such as to have shorter lengths of hospital stay) the goal of treatment for the patients studied
was often stated as being simply ‘discharge’ rather than maximisation of any aspect of their
individual abilities. Wressle et al. (2003) however repeated qualitative interviews with health
professionals after the introduction of the COPM to the rehabilitation team’s processes. They
reported that the clinicians interviewed appeared to believe the use of the COPM had
increased the involvement of patients in the goal planning process and in rehabilitation in
general (Wressle et al., 2003). They also reported perceptions of positive effects on the
patients’ awareness of their achievements in rehabilitation and on communication between
team members regarding the direction of rehabilitation interventions (Wressle et al., 2003).
Some questions were raised in this study however about the emphasis on occupational
performance in goal planning that resulted from the use of the COPM, and while benefits of
the approach were acknowledged, there appeared to be some reluctance to fully implement
the COPM at a team level on an ongoing basis (Wressle et al., 2003).
Other qualitative studies of goal planning in rehabilitation have occurred, but with a
focus on single professional groups. Two recent qualitative investigations of physiotherapy
practice again identified that patient participation in goal planning is harder to achieve than is
described as ideal in the literature (Parry, 2004; Wottrich, Stenstrom, Engard, Tham, & Von
Koch, 2004). A conversation analysis of 74 physiotherapy treatment sessions, representing
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50 hours of video-recorded conversation, found just eight episodes where the physiotherapists
discussed treatment goals with patients (Parry, 2004). In a similar vein, a study based on
interviews with ten physiotherapists and their patients concluded that physiotherapists lacked
the necessary skills to actively involve patients in goal selection even though all those
interviewed attributed great importance to such involvement (Wottrich et al., 2004). Both
these studies suggested however that physiotherapists and their patients collaboratively
produce a social context in which control over the goal planning process is unequally shared,
rather than this inequality resulting just from the physiotherapists imposing their views (Parry,
2004; Wottrich et al., 2004). Parry in particular suggested that patient participation in goal
planning might in fact be limited by constraints on the way that patients and clinicians talk to
one another (Parry, 2004). These social constraints might include the patient’s unwillingness
to offer information during goal planning discussions, perhaps due to a desire to retain a
distinction between their own understanding of their complaint and the clinician’s assessment
of it (Parry, 2004). Alternatively, Parry suggested that the patient and their therapist may
have a shared reluctance to talk directly about the patient’s functional incompetence,
something which a discussion of goal planning would require (Parry, 2004).
Some limited qualitative data have also been reported in investigations of goal planning
approaches specific to occupational therapy. Melville et al. (2002) and McColl et al. (2000)
investigated patient perspectives as part of studies into the validity and utility of the SIGA and
COPM respectively. Both studies reported that when patients were asked open-ended
questions regarding their impressions of these goal planning approaches they spoke of
generally positive experiences: that the process had helped them become more aware of
problems they were facing, that it was enjoyable or helpful; that it enhanced their motivation
for therapy or helped them focus on recovery (McColl, Paterson, Davies, Doubt, & Law,
2000; Melville et al., 2002). Melville et al. (2002) also suggested that use of the SIGA
resulted in the identification of ‘unique’ goals that might not have otherwise been raised in the
therapeutic environment. Thus these authors speculated that the SIGA could potentially
expand the scope of occupational therapy practice (Melville et al., 2002).
Lawler et al. (1999) undertook a grounded theory investigation of nursing involvement

in goal planning for people with stroke. Contrary to the opinions in other papers however,
this study found that not all specialist nurses approved of the term ‘goals’, with some stating
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that ‘goal planning’ was too formal a concept to discuss directly with patients. The nurses in
this study were concerned that conferring with patients about goals might set up an
undesirable possibility of failure or that it might require the nurses to challenge patients who
had (from the nurses’ perspective) unrealistically high expectations. These situations were
viewed as having a potentially negatively influence on the working relationship between the
nurses and their patients. Consequently, Lawler et al. (1999) reported that the nurses adopted
a ‘studied vagueness’ (p405) when it came to providing patients with information about their
recovery. Interestingly, the nurses in this study appeared to prioritise maintaining a patient’s
hope (regardless of whether or not this was considered realistic by the nurse) over providing
the patient with prognostic information or encouraging them to confront the possibility of
disappointment regarding their expected level of recovery (Lawler et al., 1999).
Of the above research, five studies investigated goal planning within a team context
(Conneeley, 2004; Holliday, Ballinger et al., 2007; Playford et al., 2000; Wressle et al., 2003;
Wressle et al., 1999). Of these five studies, three utilised quite general qualitative methods
(Playford et al., 2000; Wressle et al., 2003; Wressle et al., 1999). Playford et al.’s (2000)
paper reported the minutes from a workshop, arrived at through an unstructured group
consensus approach. Wressle et al.’s studies employed thematic analysis, generating
descriptions of perspectives on the application of goal planning in rehabilitation rather than
the development of any theory as such (Wressle et al., 2003; Wressle et al., 1999). These
studies also tended to investigate preconceptions about the way goal planning should occur.
Wressle et al. (1999) for instance reported on how well written goals matched categories from
the World Health Organisation’s International Classification of Impairment Disability and
Handicap and how well the rehabilitation service met the authors’ expectation regarding
patient involvement in goal planning.
Perhaps the most rigorous qualitative investigation into goal planning in the context of
interdisciplinary rehabilitation was the study by Conneeley (2004). However, this paper too
had its limitations. For example, Conneeley only included patients who had been involved in
goal planning, who were discharged to their home environment and who were relatively
cognitively intact (Conneeley, 2004). It is possible that these inclusion criteria resulted in a
study population who were generally more satisfied with their rehabilitation outcomes than,
for example, patients who were unable to return to their home environment or unable to
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communicate their needs. One might expect then that the study would report, as it did,
favourable experiences of goal planning (Conneeley, 2004). Furthermore, the results from
this study are presented as the product of a descriptive thematic analysis, and thus tended to
reflect the questions in the interview schedule. So, for example, the interview schedule for
participating patients included topics such as their perception of goal planning regarding
‘[their] involvement in the process… [the] focus on treatment… [and their] perceptions of
control’ (Conneeley, 2004, p255), while the reported results states that the ‘different themes
emerging from the data included empowerment and control, ownership of treatment, focus on
treatment and confidence’ (Conneeley, 2004, p251).
In summary, the small numbers of qualitative studies on goal planning in rehabilitation

have varied in methodology and the quality of their research methods. These studies have
indicated that there is some (but not complete) agreement among health professionals
regarding the importance of goal planning in rehabilitation, but that challenges exist with
implementation of what might be considered ‘best practice’ in goal planning, particularly with
regard to patient involvement. There also appears to be considerable room for further
investigation, in particular within the context of goal planning for interdisciplinary
rehabilitation. Given that different professional groups have their own discipline-specific
literature on goal planning as well as different opinions about how goal planning should best
be applied, there exists a question, for example, concerning how these different health
professionals coordinate their goal planning in a team environment. There is a need therefore
for the completion of further studies into the application of goal planning in interdisciplinary
rehabilitation. The study described in this chapter was intended as an initial venture into this
area of inquiry. This qualitative study explored the way that clinicians talked about the
functions, process and experience of applying goal planning to rehabilitation for people with
acquired brain injury within a team environment. Patient perspectives, while considered vital
for the development of health services were not sought for this particular study.
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5.2 Method
5.2.1 Research design
This study used grounded theory research methods to collect and analyse data from
semi-structured interviews with clinicians regarding their beliefs, perceptions and experiences
of goal planning in the rehabilitation of people with acquired brain injury. A Regional Ethics
Committee gave approval for this study to be conducted.
5.2.2 Participant selection and recruitment
Organisations with established reputations as providers of rehabilitation services for

people with stroke and/or traumatic brain injury were initially contacted and asked if they
would be interested in participating in this study. Managers in these organisations were asked
to provide names of clinicians who might be available for interview on the topic of goal
planning in rehabilitation. To be included in the study, participants needed to be clinicians
who had experience with the planning of rehabilitation goals for people in their service.
Participant selection was based upon purposeful sampling (Morse & Richards, 2002) to
ensure participants represented a wide range of key characteristics, such as professional
background, number of years of work experience, location of work (inpatient, outpatient, and
community settings) and place of employment (public and private organisations). As the
research developed, theoretical sampling (Morse & Richards, 2002) was used to ensure that
issues arising from earlier interviews could be subsequently explored in more detail with the
appropriate interview participants.
5.2.3 Data collection
Data collection involved the taping and transcription of semi-structured interviews with
the participating clinicians (see the Appendix 1 for a key to transcription conventions used in
this thesis). The individual participants provided signed consent before their interview. The
interviews were private and confidential with pseudonyms used to identify each participant in
the transcripts. Each interview lasted for approximately 60-90 minutes and occurred at a
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place of the participant’s choosing. Interview questions were open-ended, with an iterative
approach to the selection of topics for each interview format. In other words, following the
constant comparative method of grounded theory (Strauss & Corbin, 1990), the analysis of
initial interviews informed and influenced the types of questions and topics for discussion in
the subsequent interviews. Initially in the interviews broad questions were asked such as
‘why do you use goal planning in rehabilitation?’, ‘how do you use goal planning?’, and
‘what are some of the challenges of using goal planning in rehabilitation for people with brain
injury?’ Planned questions and probes were developed on an interview schedule to elicit
further information regarding the meaning, purpose, essential elements and challenges of goal
planning when the interview participants did not spontaneously cover specific topics.
Following the constant comparison method of grounded theory, the interview schedule was
revised between interviews in order to explore in more detail aspects of the emerging theory
in more detail.
During the interviews, data were also collected concerning the demographic
characteristics of the interview participants. This included information about the interview
participants’ gender, professional background, years of employment in the health sectors,
years of experience working in rehabilitation services, and the context of their current
employment. An ‘interview log’ was also completed following each interview to record the
primary researcher’s observations about each session and personal responses towards the
interview. A follow up phone call was occasionally required to check or clarify information
provided by the study participants in the interviews.
5.2.4 Data analysis
Data analysis occurred concurrently with data collection. The computer software
NVivo® (Version 2.0.163) was used to help organise and manage the interview data and the
associated coding of transcripts. Coding and categorisation of interview transcripts followed
the constant comparison method of grounded theory (Strauss & Corbin, 1990). This involved
reading and coding each transcript multiple times, with subsequent re-reading and coding
incorporating findings from additional interviews. Initial coding (open coding) was
undertaken on a line-by-line basis. Often these codes used the exact words and phrases from
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the interview transcripts. The relationships between and within categories emerging from this
coding were explored with increasingly higher levels of coding and conceptualisation. Data
were progressively moved to more abstract levels with the identification of emerging
theoretical constructs. These were explored in more detail with the use of memo writing and
diagrams. Data collection occurred until data saturation was reached: in other words, until I
believed that the collection of new data would not significantly result in the need to further
alter the findings that emerged from this study (Morse & Richards, 2002).
Debriefing with one or more of the thesis supervisors after each interview as well as
negative case analysis – the purposeful exploration of ‘instances that do not fit the emerging
model’ (Morse & Richards, 2002, p. 174) – were used to establish the credibility and
trustworthiness of the emerging theory. Independent review and coding of the interview
transcripts by a thesis supervisor was used to help ensure that the themes highlighted in the
analysis did in fact arise out of the data, instead of being imposed on it (Crotty, 1998). Review
and discussion of interview transcripts with the thesis supervisors also provided guidance
regarding interview technique.
Extracts from interviews are presented with pseudonyms in the results section below.
Except where the professional background of the interview participants is required for
interpretation of the extract, these have been omitted in order to preserve the anonymity of the
interview participants.
5.3 Results
5.3.1 Interview participant characteristics
Nine clinicians were interviewed. The sample included one physiotherapist, three
occupational therapists, two speech language therapists, two registered nurses (one of whom
was a clinical nurse specialist) and one clinical psychologist. The interview participants were
recruited from two publicly funded organisations and one private organisation. At the time of
the interviews, individual participants worked in one or more of the following settings:
inpatient rehabilitation, outpatient rehabilitation, community-based rehabilitation and/or slow-
stream residential rehabilitation. Four of the participants had between one to five years
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experience working in clinical rehabilitation, four others had six to ten years experience, and
one participant had over 15 years experience. All participants were female and all were of
New Zealand European/Pākehā ethnicity. These latter characteristics (gender and ethnicity)
were not used to influence the purposeful sampling of interview participants, and hence
reflected the predominant cultural group working in New Zealand rehabilitation services at
the time of the study. The full demographic characteristics of the individual participants have
not been tabulated in this chapter in order to preserve the participants’ anonymity.
The results of this study are presented in three sections: the first section explores the
value of goal planning, the second explores the purposes of goal planning, while the third
explores the relationship between issues arising from purposes and values to the challenges
and difficulties of applying goal planning in a rehabilitation context.
5.3.2 Exploring the value of goal planning in rehabilitation
The majority of interview participants expressed a strong belief in the importance of

goal planning for the pursuit of rehabilitation best practice. Goal planning was described as
fundamental to rehabilitation, with one participant calling it ‘the cornerstone of
rehabilitation’, echoing values placed on goal planning in contemporary rehabilitation
literature (Barnes & Ward, 2000; Lawler et al., 1999; Siegert & Taylor, 2004; Wade, 1998).
The importance attributed to goal planning by some interview participants was reflected in
attention to past and future development of goal planning processes, in perceptions of staff
training needs regarding goal planning, and in concerns expressed about colleagues who were
believed to be lacking the appropriate skills or understanding for goal planning. All services
involved with this study had made documented goals part of the patient records shared by the
team, and clinical meetings tended to be structured around the establishment or review of
patient goals.
The perceived value of goal planning however was explored in more depth when
participants were asked to describe what might happen if rehabilitation was attempted without
goal planning. In general, participants considered that rehabilitation would not be as
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meaningful to patients if goals were not set, that services would become aimless and that
teams would be less organised:
Researcher: What would happen in rehabilitation if you didn’t set any goals at all?
I mean could you do rehabilitation without setting goals?
Participant: Mm – probably not – oh, you could probably work towards getting
them home, but it would be more of our professional opinion of what we
feel the patient needs to be able to do, rather than asking the patient what
they want to be able to do
Researcher: What would be the consequence of that kind of approach?
Participant: We could be looking at – we could be going down completely

different lines to what the patient wants (Frances)
In contrast to this, some participants were less certain of the ultimate value of goal
planning, and, when asked to provide an account of what might happen if goals were not set,
hesitated to say that patient outcomes would be much different. For these clinicians, lack of
formal goals would not necessarily stop rehabilitation services from aiming to achieve
relevant outcomes, and at times participants expressed doubts as to whether goal planning
actually resulted in patients being offered significantly different types of interventions:
Researcher: What do you think would happen if nobody set goals?
Participant: Um, I don’t know if much would happen, yeah (laughter) - I don’t, I
mean we probably wouldn’t um might not get as far along with clients,
yeah – but that’s hard to say as well because you know I think
sometimes we probably just know what to do anyway, we like wouldn’t
necessarily need a goal to – um, look and think oh we should do this for
the client (Rachael)
Analysis of the perceived value of goal planning in rehabilitation was complicated by

difficulties that the interview participants had in imagining rehabilitation without goals.
Some participants considered goal planning to be an innate behaviour of professionals
working in rehabilitation; something that rehabilitation professionals ‘just do’ (Anna), that
‘comes naturally’ (Gail); something that health professionals have ‘always done’ (Frances).
Contradicting this idea however, were reported experiences of working with rehabilitation
teams who did not routinely or systematically set goals. One clinician for example reported
difficulty imagining how rehabilitation could possibly occur without goals, even though she
had previously stated in her interview that her team had not been setting goals when she first
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started working with them. This clinician resolved this contradiction by concluding that goal
planning must have been occurring, but in an ‘ad hoc’ or unstructured way, without all staff
members understanding what they were doing:
Participant: I can’t imagine actually a unit or any sort of rehab unit without goals
Researcher: But you were saying before you set up this process the team wasn’t
[setting rehabilitation goals]
Participant: No, yeah, there wasn’t, there – and I can’t imagine how we did it
before then… Whether it was ad hoc or… people did it but didn’t
understand what they were doing – they didn’t formalise the process, so
I think it was there but it wasn’t – I don’t believe it was – yeah, I think it
was ad hoc I suspect – and some people knew how to do it, some didn’t,
so they just relied on other people (Gail)
Confusion regarding what constituted a rehabilitation goal also complicated

interpretation of the value of goal planning. A broad conceptualisation of the term of ‘goals’
resulted in some clinicians making statements such as ‘you can’t really have rehab without
goals because you’re always working towards something, towards some improvement’
(Tracey). Here, almost any internal representation of a desired outcome, event, or process fits
within the clinician’s concept of a ‘rehabilitation goal’. Documentation or verbalisation of
goals, for example, may be considered beneficial but is not essential to fit the criterion of
‘working towards something’. One problem with this broad conceptualisation is that it
provides no distinction between goals in rehabilitation and goals in any other clinical or non-
clinical context, undermining the belief that goal planning is somehow characteristic of
rehabilitation. A second potential problem is that it appears to provide little if any framework
for communicating with others about goal planning: for instance, when attempting to reach
agreement with colleagues or patients about what is or is not considered appropriate practice
for selecting goals. In fact, as is discussed below, the participants in this study expressed
many strong opinions about how goals should be used and what constitutes an appropriate
goal in rehabilitation. What is suggested then by this broad conceptualisation of goals is the
lack of a well-developed theory of goal planning in rehabilitation; one that integrates most (if
not all) of the health professionals’ beliefs into a unified model, complete with a lexicon of
well-defined and consistently-used terminology. Again, the discourse of health professionals
in this study reflects the current state of knowledge of published literature on goal planning in
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rehabilitation, which has been attributed with a tendency to overvalue pragmatic approaches
to goal planning at the expense of the development of rich goal theory (Siegert et al., 2004).
5.3.3 Exploring the purpose of goal planning in rehabilitation:
Throughout the interviews, it was apparent that goal planning was used to serve a range
of different purposes in the rehabilitation environment. It was also apparent that the
individual clinicians differed in their use of goal planning as well as in their discourse related
to goals. Shared professional or organisational backgrounds did not appear to guarantee
shared beliefs regarding the use of goal planning in rehabilitation. Some awareness of this
issue was indicated by the interview participants however, with a number of the participants
describing the development of team processes and training around goal planning in order to
achieve greater consistency in this regard.
When asked why they used goals in rehabilitation, most participants identified two or
more possible purposes that they explicitly attributed to goal planning. Most commonly,
interview participants stated that the purpose of goal planning was to provide direction in
rehabilitation and/or the capacity to evaluate a patient’s progress or outcome. When
expanding on the use of goals to provide direction in rehabilitation, some participants related
this to a need for individualised patient treatments. Others discussed a belief in the value of
goal planning to provide direction for rehabilitation teams, with the aim of enhancing
communication and collaborations between team members. Less commonly, goal planning
was associated with achieving ‘client-centred’ rehabilitation, providing hope to patients, and
enhancing their motivation. Some participants referred to contractual obligations they had
with funding agencies, whereby planning goals for rehabilitation patients was associated with
service accountability, while one participant suggested that documentation of achievable
goals in the clinical notes provided evidence of her professional worth (see Table 7).
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TABLE 7: Purposes of goal setting explicitly identified by the clinicians interviewed
Purpose of Goal Example

Setting
To provide direction in It gives you direction as to where you should go with a

rehabilitation patient so you don’t just muck around with them, try
whatever seems to be working at the time (Tracey)
To evaluate outcomes It’s a feedback loop for the fact that - well, if you were
and monitor progress able to sign off the goals at the end, you’ve achieved what
the patients want, then it would indicate to me that it’s a
better outcome all round (Danielle)
To improve teamwork It’s a way of fostering the team working together rather
than people going off and doing their own thing (Danielle)
To practice client- It helps empower the patient, because they’ve got some
centred rehabilitation sort of control. It gives the patients and staff a focus to
meet what they [the patient] want to do (Gail)
To enhance patient Cause its what they want to achieve, I think they’d have
motivation more motivation and participate more with their therapy
(Frances)
Providing hope You’re saying well, here you are at the moment and this is
where we are heading for you, it gives a way for people to
see that there is improvement, gives them hope and things
like that (Erin)
To meet contractual The other thing about goal setting is that it’s a contractual
obligations thing as well, so it’s shows that you’re fulfilling your
[funding] contract (Danielle)
To provide evidence of I guess, yeah, probably the main thing is to show that I’m
professional worth actually doing something achievable, um, with a patient
that I can record in the notes (Tracey)
Note: To clarify, the purposes attributed to goal planning presented in this table were those
that emerged directly from the responses that participants gave to open-ended questions about
why they (and their teams) used goal planning in their clinical work. In other words, these
purposes have not been taken from the literature review presented in Chapter 2 and mapped
on to the interview transcripts.
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In these above examples, the interview participants describe an intention to use goals to
achieve specific objectives. At times however, the way the health professionals described
activities or interactions within the clinical environment implied the use of goals to achieve
other objectives that were not always explicitly recognised. These additional purposes
became apparent when analysing the way that the interview participants presented their
experiences of involving patients and families in goal planning or when discussing goal
planning within a team context.
Figure 3 presents a visual representation of the different purposes for undertaking goal
planning in clinical rehabilitation that emerged from this study. This diagram demonstrates
the complexity of the relationships between these different purposes. Figure 3 can be broadly
divided into three overlapping parts: 1) purposes relating to patient participation in goal
planning, 2) purposes relating to goal planning within a team context, and 3) purposes relating
to goal planning within the context of health funding. Each of these component parts will be
discussed individually in further detail.
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FIGURE 3: Purposes of goal planning in clinical rehabilitation for people with acquired brain injury
Goal planning within the context of health funding Patient participant in goal planning
Patient self-
determination
Evaluating
progress and
outcome
Meeting Building a
contractual Building a team Patient
approach working Hope empowerment
requirements relationship
Providing
direction
Patient
motivation
Goal planning within a team context

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5.3.4 Exploring the purpose of patient participation in

goal planning
Patient involvement in goal planning was a

frequent topic for discussion throughout all interviews.
However, the emphasis placed on patient perspectives in
the selection of rehabilitation goals differed from one clinician to the next. Opinions ranged
from strong beliefs in favour of patient participation to significant doubts regarding the value
of it. For example, one clinician (Frances) stated that the central reasons for undertaking goal
planning was to ensure that rehabilitation was ‘client-focused’, which for her necessitated
finding out what patients wanted. Conversely, other clinicians questioned the routine
involvement of patients in goal planning all of the time, claiming that it was not always the
most appropriate course of action:
Researcher: Is it important to involve patients in goals?
Participant: Yeah, that’s a really good question, um – you know what, I don’t
always think so
Researcher: Yeah?
Participant: I don’t always think so, I think it would be a really nice PC [politically
correct] thing to say that, but I think some people just aren’t in that state
to set goals for themselves (Sue)
In general, however, most of the interview participants considered patient involvement

to be an important aspect of goal planning. Typically, participants reported that information
gathered during initial assessments with patients or their families was used to find out what
they hoped to achieve from rehabilitation or following recovery from their injuries or illness.
Methods for collecting this information ranged from the use of a formal tool, such as the
Rivermead Life Goals Questionnaire (Nair, 2003), to semi-structured interviews, to informal
conversations with the patient. The interview participants stated that clinicians tended to
identify a patient’s objectives and used these to derive specific rehabilitation goals:
Usually we ask the families, ah, and the patients what they want themselves, and
then - so, we accept that as being their aims, and we record that – and then what we
would do is say well under this aim of returning home, we would look at a range of
things that they need to be able to do, and that we would be working on – and we
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would kind of rephrase it and um start setting a few measurable goals – stepwise.
(Erin)
Within this type of approach, there was often a clear distinction between the goals (or
aims) of the patient and the goals of the therapists. These two sets of goals were distinct in
that they were often established at different times, discussed in different places with different
people present, and documented separately. At times, the clinicians setting the therapist goals
were not always the same individuals as those who gathered the information about patient
perspectives.
As for other aspects of goal planning, patient participation appeared to serve a number
of purposes. In Figure 3 above, the purposes of patient participation in goal planning are
divided into four interrelated themes: ‘patient self-determination’, ‘patient empowerment’,
‘patient motivation’, and ‘building a working relationship’. This part of Figure 3 has been
expanded on in Figure 4, with the addition of a number of subheadings to illustrate some of
the concepts that were associated with each purpose. Note that some of these subheadings
relate specifically to one purpose while others relate to a number of the purposes and are
therefore placed at the intersections between purposes. Also, note that more of the
subheadings in Figure 4 populate sections relating to the themes ‘patient self-determination’
and ‘building a working relationship’. This is because analysis of the interviews for these
particular themes resulted in more complex, multidimensional concepts than emerged from
analysis of the two other themes. ‘Patient empowerment’, in particular, while emerging as a
discrete theme from the interview transcripts, was infrequently identified as a reason for
undertaking goal planning in rehabilitation. Only two of the interview participants related
‘patient empowerment’ to goal planning. It is therefore represented by a broken line in Figure
4.
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FIGURE 4: Purposes for patient participation in goal planning
Patient self-
determination
Witness to goal planning
Informed consent
Learning more
about the patient
Individualisation
of treatment
Building a working
relationship Patient
Hope
empowerment
Buy-in
Teaching the patient Patient setting
about rehabilitation the agenda
Avoiding conflict with
patients
Controlling the
direction of
therapy
Patient
motivation
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5.3.4.1 Patient self-determination
Using goal planning for the purpose of influencing

‘patient self-determination’ related to the way clinicians’
spoke about the involvement of patients in clinical
decision making. Analysis of the interview transcripts
revealed a range of different levels of patient self-determination that were permitted or
encouraged by the clinicians during the goal planning process. Three broad levels of patient
self-determination, forming a continuum of increasing autonomy, were identified: a) Witness
to goal planning, b) Patient buy-in, and c) Patients setting the agenda.
5.3.4.1. a) Witness to goal planning
At one end of the range of levels of self-determination was the situation where patients
were not actively involved with planning their goals, but were informed when goals had been
set on their behalf. Patients ‘participated’ only to the extent that they witnessed the goal
planning process and so could react once goals had been established. In this context however,
no processes were in place to provide them with control over goal selection:
When my patient comes in on the ward, I look at them and think, right, you’re only
ever going to get to a wheelchair or yes, we’re going to get you walking – so that’s
your big achievable goal – but working with the patient you’ve got to explain, like
this is today, this – if you can do this, it’s a part of the next step (Anna)
Thus, the approach to goal planning illustrated above aligned with a philosophy of
medical paternalism, whereby the clinician made decisions on behalf of her patient with the
intention of doing so in the patient’s best interest. In general, most of the other interview
participants were more circumspect regarding clinicians prescribing rehabilitation goals for
patients. However occasionally other participants did describe situations where it was
considered appropriate to pursue goals that had not been set in consultation with patients. For
example, Sue (an occupational therapist) stated that while rehabilitation could be more
difficult when working with someone who is unable to set goals, there were some
circumstances in which patients welcomed a more therapist-directed approach to intervention.
However, in this context goal planning may be completely avoided (or at least postponed):
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If somebody can’t or won’t set goals, if you’re doing an intervention with them
and they’re not engaging because they’re choosing not to, well then of course it’s
going to be really hard to do rehabilitation, but I think there’s a difference with
somebody that can’t set goals because they don’t want to, or they’re not in the right
frame of mind, but then when you actually do your intervention with them, they’re
happy to do that, and for some people setting a goal is too scary, and they’re
actually happy for you to come in and do some work, and just see where it goes
(Sue)
5.3.4.1. b) Patient buy-in
In the literature on ethics in health care, the issue of championing patient autonomy is
frequently associated with the concept of ‘informed consent’ (Hass, 1993). Some of the
interview participants described a variant of informed consent achieved by having patients
sign a document listing goals for their rehabilitation. In this study however, informed consent
did not emerge from the interview data as a discrete category related to the theme of patient
self-determination. Where it occurred it was always associated with a much broader concept,
which came to be labelled ‘patient buy-in’. Buying-in to goals was distinct from informed
consent because it required a component of personal commitment from the patients (and/or
their families). Where examples of this arose in the interview transcripts, clinicians described
the patients being asked to do more than just consent to a medical event: they were also being
asked to agree to work with the team on the specified goals. For many rehabilitation
interventions (such as therapeutic exercise, cognitive retraining, and vocational rehabilitation)
active patient participation is required if the intervention is to occur, let alone succeed. A
number of the interview participants suggested that patient involvement with goal processes
was one way to accomplish this buy-in. Again, achievement of patient buy-in to goals did not
necessarily require the involvement of patients in the selection of goals. In other words, it
appeared possible (from the clinicians’ perspective) to achieve buy-in just by discussing
therapist-determined goals with patients, rather than necessarily needing the patient’s to be in
charge of selecting the goals for treatment:
So everybody should use the goals, and what we’re trying to get is that even the
people who aren’t involved with setting the goals are aware of the goals so that
they can buy into them (Danielle)
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The act of buying-in to rehabilitation goals carried with it the suggestion of patient
choice; that patients could make a decision to (or not to) agree with and follow the plans of
the health professional. This then is how ‘buying-in’ to goals related to the concept of
‘patient self-determination’. However, the notion of getting patient buy-in also carried with it
a suggestion of manipulating this patient choice; that the therapists were using the discourse
of goal planning to market certain elements of the rehabilitation process to patients or to
promote certain activities that were considered more clinically important. A patient may not
be inherently inclined towards the activities in question, and so might be asked to make an
active decision to agree with the ‘expertise’ of the health providers. Thus the notion of
‘patient buy-in’ was also related to the concepts of ‘building a working relationship with
patients’ and ‘enhancing patient motivation’.
5.3.4.1. c) Patients setting the agenda
Beyond ‘buying-in’ were goal planning processes whereby patients were identified as
actively directing how the rehabilitation was to proceed. When examples of this appeared in
the interview transcripts, the most common approach described was to allow or encourage the
patient to set the overall direction of the rehabilitation, with the clinical staff selecting the
‘short term goals’ (or ‘steps’) towards the patient’s ultimate objectives. Often this approach
was described as combining patients’ reports of their ‘wishes and wants’ with information
from professional interdisciplinary assessments, such that even when patients were involved
with ‘setting the agenda’ in this way, the selection of goals for rehabilitation was often still a
negotiated process. One interview participant (Erin) for example, talked about ‘rephrasing’
the patient goals to fit a more ‘appropriate’ format for clinical documentation. In particular,
this involved making the goals ‘measurable’ – a characteristic that clinicians deemed
important for goals but which they stated patients frequently omitted when asked to talk about
their goals.
Of course, if patients were to be truly autonomous in rehabilitation then it could be

suggested that their goals should be the focus of rehabilitation regardless of whether or not
clinicians agreed with them. It would also be permissible for patient perspectives to
supersede medical or health professional advice. Patients would be allowed to make and learn
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from their own mistakes and their values would be used to determine the domains by which
the success of the rehabilitation was evaluated. A few of the interview participants had
explicit strategies for managing patient goals when they differed from the clinicians’
recommendations. One solution offered by Gail, who worked in inpatient rehabilitation, was
to defer conflict with patients regarding their goals by framing them as ‘long term goals’. In
this context, a ‘long term goal’ referred to a goal that was not necessarily addressed during the
period of rehabilitation that occurred in the inpatient setting:
Researcher: What happens when patients insist on goals that the team disagrees
with?
Participant: That’s fine too - because you can have short term and long term
goals… that might be something that we discuss that maybe they do
want, but over time hopefully they achieve it, but they may not achieve
it in the inpatient setting, and that’s usually acceptable, that’s fine (Gail)
As a caveat to this however Gail added that clinicians had a responsibility to be honest
with patients in telling them, from a professional clinical perspective, how great the divide is
between their current disability and the goal that they wish to achieve:
Occasionally you do see someone with unrealistic goals, you see that from day
one, so you keep very honest in telling them how they are going, at this stage, and
the goal that they want seems quite a long way away (Gail)
In other settings however, this deferral of confrontation with patients regarding goals
was not always possible. Sue, who worked for a community-based rehabilitation service,
provided an alternative approach to dealing with patient goals that differed from her clinical
recommendations. She described a framework that required a decision to be made regarding
whether a patient’s goal was ethical, whether it was safe, and whether it required work that
was within her professional role. If the goal met these criteria, Sue stated she would accept
the goal, but added as a rider that she tended to increase the detail of her clinical
documentation in order to protect herself professionally. Thus, it emerged from the
interviews that encouraging patients to take control of goal planning necessitated some
evaluation and management of risk:
Researcher: Um, what happens if a patient has goals that the therapist doesn’t
agree with…?
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Participant: Yeah, well yeah, I think that situation comes up quite a lot, um, (sighs)
I guess, yeah, I have certain guidelines… I may not agree that that’s the
most important goal that they want to work on in terms of the timeframe,
but provided that it’s not unsafe, or it doesn’t go against any like ethical
things that I like have as a therapist, then I will do that goal with them,
yeah - provided that it’s still within the remit of my - of my job, I will do
that, but that’s when I start to document really, really closely (laughs)…
(Sue)
In general however it was apparent that other philosophies, perceived responsibilities

and work pressures influenced the degree to which health professions allowed patients to
autonomously select their own rehabilitation goals. For example, one clinician indicated that
she was aware of having a professional drive to direct patients towards endeavours deemed
more clinically appropriate while at the same time being aware of the need to allow patients to
have some control over decisions about their therapy:
So I think our clinical judgment does sort of like try and refocus them, but at the
same time say well it’s you’re decision, what do you still want to be able to do
(Frances)
5.3.4.2 Patient empowerment
As mentioned earlier, the concept of ‘patient

empowerment’ emerged as a discrete but infrequently
identified reason for undertaking goal planning in
rehabilitation. Only two of the interview participants discussed the relationship between goal
planning and patient empowerment, whereas others did not mention it. Gail linked the
concept of ‘patient empowerment’ to the concept of ‘patient self-determination’ stating that
goal planning ‘helps empower the patient – because they’ve got some sort of control’. In
Gail’s interview, she indirectly linked the process of goal planning to education of patients
about rehabilitation. Sue, on the other hand, was more explicit about a perceived mechanism
by which patients could become empowered via the goal planning process, stating that in
some circumstances she actually wrote goals that were intended to reflect increasing
empowerment. She related this to the ongoing development of her clinical expertise, where
she had started to move away from prescriptive approaches to goal planning and towards a
more flexible ‘patient-centred’ approach:
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Now [when planning goals] I tend to use things like – will be able to successfully
identify their individual skills, or I think I use the words more like gaining
awareness, so I think I see it more as like the goal of actually empowering them to
realise things about themselves rehab-wise… leaving it more open to them to make
a decision as to where they want to go with that (Sue)
It is interesting to note that this type of empowerment-oriented goal planning appeared

to result in the selection of goals that deviated somewhat from what might be considered the
more traditional focus in rehabilitation: physical function. Indeed, when talking about this
aspect of goal planning, Sue was referring specifically to patients whose problems with
cognitive function limited their ability to participate in social activities (e.g. work, education,
and relationships). The resultant goals were also less specific and less measurable than might
normally be considered ‘best practice’ in rehabilitation. This was an approach to goal
planning that Sue intentionally took in order to further her aim of using goal planning to
empower her patients.
5.3.4.3 Patient motivation
A few interview participants identified that goals

might increase a patient’s motivation to participate in
rehabilitation, thereby improving their outcome. For
example, Frances linked ‘patient motivation’ to her concept of client-centred therapy, stating
that focusing on what a patient wanted to achieve from rehabilitation would result in the
patient ‘[having] more motivation and participate more with their therapy’ (Frances).
Alternatively Rachael related the purpose of involving patients in goal planning to her own
experiences of being motivated by goals:
Researcher: And why is it important to involve the client?
Participant: Just for their own motivation – like, I know myself I’m a real – I like
to have my own things set out, you know, and if I – I just put myself in
the client’s shoes, and if I had say a sheet of paper on the wall with three
goals I’d be real motivated to achieve them, you know? (Rachael)
Other interview participants agreed that there might be a link between goal planning and
patient motivation only after being prompted to consider it. In other words, ‘patient
motivation’ was a naturally emerging concept related to goal planning for some but not all
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interview participants. When asked to consider a mechanism by which goals might achieve
this enhanced motivation, a number of these clinicians were able to provide an explanation
based on positive reinforcement resulting from achievement of goals. This indicated that they
did have some conceptual association between goal planning and motivation, just not an
association that was in the forefront of their minds when they were thinking or talking about
goal planning in rehabilitation. In the context of goal achievement resulting in positive
reinforcement, these clinicians believed that patient goals needed to be ‘small’: in other
words, likely to result in success. In a similar vein, the clinicians also believed that ‘if you set
[a goal] beyond a patient’s reach then it just… puts patients off’ (Tracey). In other words,
some health professionals believed that failure to achieve a specific goal could result in
detrimental psychological effects for patient:
Researcher: In the inpatient environment, do you think goal setting could have a
place for motivating patients?
Participant: Yeah, I think it could
Researcher: And how do you think that might occur?
Participant: Um, if you set small ones for them, ones that they can see the benefit
of doing, they – one patient was able to communicate basic needs for
how he wanted his cup of coffee to someone through a communication
chart, and making that a goal, he was able to get some intrinsic rewards
from that and then he’s also able to see how it, how it helps him in terms
of being able to make an improvement up the hierarchy of getting better
(Tracey)
While ‘enhancing patient motivation’ was identified as a reason for using goal planning
in rehabilitation, it was neither the most prominent feature of patient involvement in goal
planning nor the most highly prioritised objective of goal planning. In other words, while
clinicians acknowledged that goals could be used to motivate patients, in practice this was not
generally a priority for the clinicians. When asked specifically about this, a number of the
interview participants related this to the stage their service was at in the development of a
team approach to the practice of goal planning, stating that their service had concentrated first
on establishing goal planning processes that were shared by the clinicians in the team. While
goals were discussed with patients and documented in the patient’s notes, they tended not to
be presented to the patient in such a way as to provide them with a target to strive towards.
When considering future developments of their team’s processes, several of the participants
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mentioned the need for greater patient participation. However, this too tended to focus more
on other objectives, such as enhancing patient self-determination or improving patient ‘buy-
in’ to rehabilitation, rather than specifically enhancing conscious motivation:
Researcher: So who is goal setting for?
Participant: It’s for the whole team, which includes patient and family
Researcher: Right – and who uses the goals?
Participant: At the moment it’s the health professionals, but again, what we are
looking at doing is that because the patient is going to be signing off that
the patient owns the goals, and we’re using them to feed into, into that -
doesn’t quite happen like that at the moment, but again I think… cause
we changed things relatively recently, I think that’s where we are going
with it. (Danielle)
In fact, when specifically talking about the relationship between motivation and goals,
some of the participants focused more on discussing ‘motivation’ as a prerequisite to goal
planning and rehabilitation rather than a product of goal planning (i.e. something that could be
influenced by goals). In the inpatient environment, the presence of unmotivated patients
raised questions of ‘inappropriate referrals’ to rehabilitation, while in the outpatient setting
one interview participant implied that patients with low motivation tended to be discharged
from the service:
Researcher: Which is easier? Setting goals in the outpatient setting or in the

inpatient setting?
Participant: Outpatients
Researcher: Right, and – why do you think it is easier in the outpatient setting?
Participant: Um, because they are motivated and – they, the patient themselves are
aware of what they want out of therapy or they don’t come… If they’re
not [motivated], we just give them advice and send them on their merry
way really (Tracey)
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5.3.4.4 Building a working relationship
While not explicitly identified by the participants as

a reason for undertaking goal planning in rehabilitation,
‘building a working relationship’ emerged as a core
theme in the interviews. ‘Building a working
relationship’ related to the use of goal processes or goal discourse to establish or influence the
relationship between clinicians, patients and their families. Frequently the interview
participants referred to building a ‘partnership’ or developing ‘rapport’ with patients. Some
participants expressed the belief that patients should be considered part of the rehabilitation
team, rather than just the subject of the team’s efforts. Goal planning was often central to the
development of this relationship, with the process of goal setting being attributed with
‘opening up of dialogue’ between the clinician and the patient and supporting the concept of
‘client-centred’ rehabilitation:
So I think, yeah, having a goal does allow, um, you to have a relationship with
clients where they know what you are working on… yeah, it brings you together, I
think - it really does bring you together, yeah, and you know, if you’re working
really hard to have like client-centred goals then it opens up the dialogue for that,
and it opens up the chance to say well, you know, gosh if that’s what you really
want to work on, and that’s what you’re feeling, I don’t know if I can offer that as
a therapist, but you know can we meet in the middle? (Sue)
Analysis of the interview transcripts however revealed that the clinicians used goals to
influence working relationships with patients in a variety of ways, not all of which were
necessarily directed at client-centred practice. Four ways of using goal processes and goal
discourse to build a working relationship with patients were identified, each of which will be
discussed in turn:
a) Learning more about patients (their lives and their individual needs)
b) Teaching patients about rehabilitation (the language of rehabilitation and the
skills required to actively engage in rehabilitation)
c) Maintaining authority and directing the rehabilitation process
d) Avoiding conflict with patients
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5.3.4.4. a) Learning more about patients
As discussed above, goal planning processes frequently involved an assessment of the

patient’s needs and desires. For example Erin stated that ‘usually we ask the families… and
the patients what they want themselves’. In this way, discussions with patients were used to
determine their priorities and values, particularly with reference to their newly acquired
disability. Of course, in part this also related to the concept of encouraging ‘patient self-
determination’.
There was a suggestion in some interviews that the process of extracting individual
patient responses to disability and rehabilitation required a certain degree of professional
experience and expertise. Danielle gave an example of a situation in which a detailed
discussion with a patient resulted in a rehabilitation goal being identified that was different to
the one documented in the patient’s notes. This new goal allowed the patient to exit inpatient
rehabilitation and return home sooner:
So we’ve got a guy who’s a multi-trauma patient on the ward at the moment, and
he’s been in for about a week, and one of the other therapists has seen him and
they’ve written goals for him around you know being independently mobile with a
stick and you know - so quite high level stuff, but when I sat down and spoke to
him, he just wants to go home, and he’s quite happy to go home walking a short
distance with a frame, you know, so his idea of going home and managing in the
short term is very different from the goals that have been set, and I’m not quite
sure why there was that disparity, but by taking a bit more time initially to tease
that information out it becomes - it’s a whole different ball game - getting someone
home with a frame and someone home with a stick, you know, you can get
outpatient stuff sorted once he’s at home… but it’ll make a huge difference time-
wise to when this guy can go home (Danielle)
Danielle stated that teasing out information regarding the patient wishes and
perspectives takes time, implying that this was not something which could be achieved
through routine application of a standardised set of questions or assumed on the basis of the
patient’s initial presentation. As Danielle later stated, ‘the thing that hits you first when you
look at a patient might not be the problem that you actually need to treat’. Danielle described
this as a skill that is gained over time and one that new graduate clinicians do not necessarily
have when they enter the workforce.
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Similarly, Sue described how her approach to goal planning had changed over time. In
particular, her approach to goal planning had increasingly become more flexible and less
prescriptive. For example, she stated that in comparison to earlier in her career she was now
more inclined to alter or even stop pursuing a goal before the preset timeframe if it became
apparent that the original goal was no longer relevant to the patient’s evolving objectives.
This, she believed, allowed her to be more responsive to her patients’ changing needs.
Ongoing discussions of goals with patients therefore became a way of continually monitoring
the patient’s perspective regarding the relevance of current rehabilitation interventions:
I still set timeframes with people, but I think every session that I have with
somebody, I’m kind of like reviewing it or getting them to be more open with me
as to whether it is the right direction that they want to go in, um, yeah I just see it
as a more evolving, evolving process - does that make sense? (Sue)
Even, Anna, who had what appeared to be the most prescriptive approach to goal
planning (allowing patients only to witness goal planning rather than actively participate in
the selection of goals), monitored her patient’s responses to goal-oriented activities in order to
learn more about their mood and attitude. She described using the patient’s daily response to
their goals as a means of evaluating their general disposition and to judge how much she
should ‘push’ them in their rehabilitation.
5.3.4.4. b) Teaching patients about rehabilitation
A number of the interview participants stated that some patients were admitted to their
service without any real idea of what rehabilitation was or what it involved. Discussion with
patients about goals and goal planning was identified as one way of teaching them about the
process of rehabilitation and giving them the skills to maximise their involvement in
rehabilitation. Gail for example stated that goal planning ‘describes what rehab is’ and that it
makes it ‘more tangible’ for patients. For Gail, goal planning differentiated rehabilitation
services from ‘just a ward where you stick people’. This suggested that goal planning could
be used to introduce patients to the idea that successful rehabilitation required their active
involvement. Similarly, Danielle described using goals to assist patients and their families to
learn about what rehabilitation is, and linked this to the concept of maximising patient ‘buy
in’ into therapeutic activities:
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Some of the patients that we get that come to rehab, don’t know why they’re there,
so if - they don’t know why they’re there, they don’t know what they’re doing,
they don’t know what’s going to happen - you’re not going to get their buy-in,
you’re not going get their best effort, you’re not going to get the family realising
what’s happening, so, I think it’s vital at the start to get all that, so again you start
the process, you set it off in the direction you want (Danielle)
In situations where treatment goals tended to be set by the clinicians, discussion with
patients about goals was also described as a way of informing patients about how clinical
recommendations fitted with their own objectives. For example, a number of participants
talked about using goals to teach patients about the ‘steps’ that they need to achieve before
they could successfully reach their own objective (such as to return home). Underlying this
was the belief that patients often needed assistance to see the relevance of therapeutic
activities or to understand the ‘correct’ order of events that needed to occur during their
recovery. Goal planning was therefore suggested as a means of educating patients about these
issues:
We talk along side them… and we say, of course you want to go home, what are
the stepping stones to going home, and it’s one step at a time, and once they
understand that concept, um, but yes, if they can do this – then they can move on
and do this (Philippa)
Teaching patients about goal planning in this way seemed to indirectly link with the
concept of ‘patient empowerment’. When patients are provided with information about how
clinicians think and talk about rehabilitation, they are given the opportunity to engage more
actively in the process of clinical decision making. (This of course is somewhat dependant on
the patient’s cognitive and communicative skills.) However, as will be discussed next, the
discourse of goal planning appeared more often to be used by clinicians to maintain their
control over decisions and activities in rehabilitation.
5.3.4.4. c) Maintaining authority and directing the rehabilitation process
Throughout the interviews, a number of examples were given where discussions about
goals with patients were used to correct or redirect patients who were deviating from what
was considered the most clinically appropriate course. For example, Frances described a
common approach that involved identifying for patients the discrepancy between their current
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capabilities and their personal objectives (such as to return home). Here, however, the
patient’s goal was seen as important to identify, not because it was considered attainable or
because it should be the objective of interventions, but rather for its potential to be used as a
lure to encourage the patient towards rehabilitation activities considered more relevant by the
clinician:
When you’ve got some patient that’s not got any insight, and it’s a dense hemi that
wants to go home, and you just know that they’re not going to be able to cope, that
lives alone – then there is going to be conflict, but then you sort of [say] we’ll have
to work towards them, to sort of, you know, this is what you want to achieve, but
first if you can’t sit up or can’t brush your teeth, and you live alone, how are we
going to get you home? (Frances)
Similarly Philippa gave an example of a situation where a discussion of goals was used
to redirect a patient who had disrupted an established ward routine. On this occasion, the
goals were used as a way of justifying a recommended rehabilitation strategy to an articulate
and challenging patient:
With this particular one, because he was very clever, and as soon as he came out of
[post traumatic amnesia] he was articulate plus, plus, plus… so he challenged…
some of the nurses, the rehab workers in particular… so over a holiday weekend,
he more or less took control of what he was going to do – or not do… but by
having measurable goals in place, and by sitting him down and explaining the
processes again come Monday – he had the intellect to adapt and listen – certainly
to the therapists (Philippa)
Gail provided yet another situation where goals could be used to maintain control over
the rehabilitation process. The following example was part of a discussion with Gail about
‘challenging’ patients who, while not common, were considered significant in that they were
seen to have the ability to damage relationships within a rehabilitation team by ‘playing [staff]
off against one another’. Gail suggested that diligently following set goals provided a way to
minimise the impact that these types of patients were believed to have over the team and the
rehabilitation process:
You’ll always get the complex, challenging patients – I can think of perhaps two or
three in the four years that I’ve been in the service here that have been a real, um,
challenge, um, and can tear a team apart... if the team sticks to the goals, sticks to
the process, it can’t be torn apart and played off against each other, and can keep
the patient to the goals that they originally set, in order to achieve what they
wanted to achieve, without high-jacking the process (Gail)
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The above three examples illustrate a subtle distinction between using goal planning to
promote patient self-determination and using goal planning to direct or influence patient
choice. Making this distinction highlighted inconsistencies in some of the rhetoric of the
clinicians interviewed. For example, Gail stated a number of times earlier in her interview
that patients needed to be reassured that the goals they set at the beginning of rehabilitation or
before admission can be changed by them at some later stage. Gail linked this flexibility in
goal planning to the concept of patient autonomy, but also to building rapport with patients.
As shown in the above extract from the interview transcripts however Gail suggested that in
some circumstances holding patients accountable to pre-agreed goals was a key component of
managing difficult interactions between patients and staff. In other words, goal planning
approaches appeared to be conditional; dependent not only on the abilities of the patient, but
also on the values and view of the clinician at the time. Ultimately, the clinicians made the
rules about goal planning, so were in the position to dictate when goals need to be pursued
and when they could be altered or abandoned.
5.3.4.4. d) Preventing conflict with patients
Another example of using goal planning to ‘build a working relationship’ involved the
use of goals to prevent misunderstanding, miscommunication, and conflict between patients
and their clinicians. Danielle emphasised that goal planning could facilitate clearer
communication between patients and therapists regarding their expectations for therapy
during an episode of rehabilitation:
Personally speaking I think it saves a lot of fire-fighting down the track, so that the
problems that we’ve had with patients and families getting angry as you come up
to discharge, I think would have been stopped by getting them involved in the
process right from the beginning, which is what we are trying to do now, and just
that whole communication thing, if you’re, if you’re being open and talking to the
patient right from - and the family - right from the beginning, there won’t be any
surprises down the track, and I think it’s those surprises and - What do you mean
the patient’s coming home like this? Or – What do you mean that they can’t come
home? - If you’ve got the whole process laid out, and goal-setting as I say, is the
beginning point of that, then it save all the nasty surprises or cuts down on the
nasty surprises down the track – (Danielle)
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This example above also highlighted some of the complex characteristics of the
relationships between patients and clinicians that are distinct from other settings in which goal
planning is applied. For instance, unlike industrial-organisational settings (where goals are
set for teams by themselves, an employer or a contractor), in the rehabilitation setting the
subject of the goal (the patient) is in equal parts a consumer of the service and a participant in
the production of the service, as well as being part of the ‘outcome’ by which the quality of
the service is judged. The relationship that the clinicians develop with their patients needs to
accommodate all these roles.
As a final point here, it is worth noting that the theme of using goal planning to ‘build a
working relationship’ applied as much to the patients’ families as to the patients themselves.
In other words, goal planning also appeared to be used to learn more about a patient’s
families, to educate families about the rehabilitation process, to gain the ‘buy-in’ of family
members to the rehabilitation process, and to prevent potential conflict with family during the
delivery of rehabilitation services. Discussion of goals was also described as being used to
confront family members over their ‘unrealistic expectations’ regarding potential
rehabilitation outcomes; thus attempting to direct attention toward clinical activities that the
clinicians considered more appropriate. Furthermore, in family meetings, goals were
described as being used to keep discussions on topics that were considered most important by
the health professions, and therefore as a way of avoiding ‘other issues’ which were
considered peripheral to the patient rehabilitation. Again, goal-related discourse provided a
rhetorical means by which clinicians could maintain control over the rehabilitation process
and authority over what is considered legitimately within the domain of rehabilitation:
We get quite difficult families in here sometimes and um [goal planning is] quite a
good way of just bringing the meeting back to, you know, the focus of why we’re
there, and not getting caught up in other issues, yeah (Rachael)
5.3.4.5 The place of ‘hope’
Related to the concept of ‘building a working relationship’ with patients and family, but
equally related to the three other identified themes involving patient participation in goal
planning was the concept of using goals to promote ‘hope’. While not the primary reason
expressed for undertaking goal planning, the concept of ‘hope’ was linked to many of the
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discussions regarding its purpose in rehabilitation. Goals were seen to bring hope to patients
and their families by providing them with ‘direction’, and giving them information about how
rehabilitation was likely to progress. ‘A goal’ Tracey stated ‘keeps hope alive in patients’.
Equally, ‘hope’ was seen to arise out of patient satisfaction and feelings of success when
goals were achieved, and therefore was expected to contribute to a patients’ ‘motivation’ for
further therapy:
You’re saying well, here you are at the moment and this is where we are heading
for you, it gives a way for people to see that there is improvement, gives them hope
and things like that (Erin)
The interview participants were careful to make a distinction between ‘hope’ and
‘unrealistic expectations’. ‘Hope’ was associated with maintaining a positive attitude toward
potential recovery. ‘Unrealistic expectations’ were described in terms of inappropriate beliefs
regarding prognosis given one’s current pathology or disability. Making this distinction in
practice however was described as a ‘tricky balance’ (Erin). The clinicians reported feelings
of mixed responsibilities toward adequately informing patients about what they saw as the
clinical realities of acquired brain injury, while still allowing patients to retain their own
vision for the future. While the clinicians unequivocally believed that ‘hope’ belonged to
patients (and their families) and that health professionals had no right to take away someone’s
hope, incorporating a patient’s hopes into the discussion of goal planning was considered
complicated. There appeared to be no clear guidelines that could be followed when striving
to achieve this balance between ‘hope’ and ‘realistic goals’ in rehabilitation:
We explain to him that it was unrealistic at the time – that was his, his um – I
suppose, reason, I suppose, for carrying on, I mean you can’t take sort of away
someone’s hope either, but you can’t give them false hope – so it’s sort of, as you
know, goal setting is ah, it’s not an exact science (Gail)
5.3.5 Exploring the purpose of goal planning within a

team context
When discussing the value of goals, the interview

participants frequently referred to a belief in the capacity
of goal planning to enhance the quality of teamwork within a rehabilitation service. Most
often, shared goal planning was believed to enhance teamwork as a result of the effect of
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goals on communication between team members. Goal planning was also attributed with
providing a much-needed structure to inter-professional interactions; or as one participant put
it, ‘it makes your processes a lot snappier’ (Gail). Improvements in teamwork through goal
planning were closely linked to the concept of goals ‘providing direction’ and being a means
of ‘evaluating progress and outcome’. Consequently, goal planning was presented by the
interview participants as an important means of building and maintaining relationships within
a rehabilitation team:
Researcher: Why set goals?
Participant: Because otherwise we’d all be running off in fifty thousand different
directions (Anna)
In many interviews, research participants described how much attention had been paid
on an ongoing basis to developing processes for a team approach to goal planning. Some
interview participants described project work that they had been involved in, which focused
on the way goal planning was integrated into their team activities. Goal planning was
described as enhancing the productivity of team meetings, providing greater transparency
around clinical decisions made by the team, and with improving collaboration between team
members regarding rehabilitation interventions. The interview participants believed that team
meetings had become more ‘focused’ as a consequence of shared goal planning, with one
participant, Danielle, stating that a new goal-oriented format for team meetings resulted in
‘cutting down on the unnecessary chatter’.
It’s a way of fostering the team working together rather than people going off and
doing their own thing, so we’re looking at seamless service and getting what the
patient wants and I think if you are setting team goals, that’s the first step to doing
that, because otherwise everyone goes in and does their own bit, and it’s not
defined as to whose going to do what and you’d be getting overlap but also you’d
can get disparity between the different um – groups (Danielle)
Analysis of the interview data also revealed that goal planning was associated with the
development of a greater sense of team unity. Prior to the introduction of goal-oriented
formats, team meetings were described by the interview participants as being structured
primarily around the provision of information (for example, allied health professionals
informing medical staff about their activities and assessments) rather than around collegial
approaches to decision making or therapy. In addition to this, discussions within the team
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about goal planning and goal achievement contributed to the development of a shared self-
knowledge, both in terms of an overall understanding of the clinical progress achieved by
individual patients as well as in terms of a better appreciation of one another’s roles within the
team:
When we meet weekly… and discuss what level we are all at for those goals, you
get an overall impression of where everybody’s at (Philippa)
Finally, team discussion of patient goals was also described as introducing greater
accountability within the team. Goal planning as a team activity encouraged health
professionals to ‘put money where their mouth was’ (Danielle) regarding what therapeutic
activities they intended to pursue with individual patients and introduced the requirement to
report back to the team on the degree of success achieved following these interventions:
Participant: We are also trying to get people being responsible for what’s going to
happen next kind of thing -
Researcher: Responsible to who?
Participant: To – to the team really I think, because I think what – as I say, the
process that was happening before it was all, we sort of, we’d have the
meeting, it would go on for hours, and at the end of it, you’d just go off
and do your own little bits again, whereas again I think we are trying to
foster that team kind of ethos, and that as I say there is clarity [about]
where we are going from here, using the goals as starting point for how
the patients are treated during their stay, and that it is clear as to who is
going to be involved with what (Danielle)
Through all discussions of goal planning within a team context was the ongoing theme
of using goals to ‘build a team approach’ to rehabilitation. This purpose frequently
overlapped with the identified purposes associated with involving patients in goal planning.
For example, when a patient’s perspectives and opinions were sought in relation to the
direction of the team’s approach to rehabilitation, the purpose of goal planning to ‘enhance
patient self-determination’ influenced the ‘building of a team approach’ via the ‘building of a
working relationship’ with the patient. Alternatively, this overlap occurred when the
‘building of a team approach’ resulted in goal planning being used to influence the ‘building
of a working relationship’ with the patient in order to ‘maintain authority and direct the
rehabilitation process’. Overlaps also occurred between using goal planning for ‘building a
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team approach’ and goal planning for the purpose of ‘meeting contractual requirements’. The
relationships between these purposes will be discussed in the following section.
5.3.6 Exploring the purpose of goal planning within

the context of health funding
Less discussion occurred during the interviews

regarding goal planning for the purpose of ‘meeting
contractual requirements’ than for the other purposes mentioned so far. However, for the
majority of interview participants, their team’s current approach to goal planning had been
substantially influenced by the expectations of health funders, and in particular ACC, who
required the clinicians to report on goals as part of their contractual obligations. For a few
interview participants funding was the first consideration when asked to comment on why
they invested time on goal planning activities. Here, goals were equated with accountability.
The documentation of goal planning and goal achievement was described as ‘proof’ of the
quality of rehabilitation. This purpose required the goals to be measurable (so they could be
objectively evaluated by a third party) and attainable (as unattained goals would not provide
the anticipated evidence of clinical work):
Researcher: What do you see is the reason why you do goal setting in the rehab
setting here?
Participant: Because above everything – we’re funded – so most importantly we’re

answerable, and by answerable things need to be measurable, functional,
and attainable, otherwise quite simply why have rehab? Anybody could
do it. So it must be very specific (Philippa)
The concept of using goals for the purpose of ‘meeting contractual requirements’ was
closely linked to using goals for the purpose of ‘providing direction’ and for ‘evaluating
progress and outcomes’. However, in this context, ‘direction’ was conceptualised as moving
towards outcomes of interest to the health funder. At times, the interview participants
suggested that the health funders wanted rehabilitation to move towards outcomes that were
meaningful to the patient (in other words, goals needed to provide objective evidence of
patient involvement in decision making) but equally in this context, it was believed that the
documented goals needed to direct services towards financially relevant outcomes (such as
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discharge from inpatient facilities by a pre-specified date). Thus in the context of ‘meeting
contractual requirements’ the concept of ‘evaluating progress and outcomes’ developed a
more business-oriented significance. Here, as one interview participant put it, the purpose of
goal planning was about ‘determining whether we [the rehabilitation team] were doing our job
or not’ (Erin).
Different funders were described as having different levels of expectation regarding

goal planning processes. ACC was described as expecting and monitoring the documentation
of goals for individual people receiving rehabilitation under their contracts, while the Ministry
of Health was reported not to have this direct reporting requirement. Some changes made to
the interview participants’ goal planning practice had occurred because of the perceived need
to better meet the contractual requirement for their ACC-funded patients. These changes
were considered to result in improved team practices and so were largely accepted by the
clinicians. Evidence of this was revealed by the adoption of these changes to goal planning
processes for all patients in the interview participants’ services rather than simply just those
patients funded by ACC. However, some interview participants still rebelled a little at the
thought of a health funder being too dictatorial regarding the direction of the rehabilitation
services that they provided. In general, the interview participants considered themselves
advocates for their patients rather than merely tools of the health funder:
Most of the time I don’t care about the funders… I don’t even give a toss you
know, because I’m actually here to [provide therapy] – (Philippa)
5.3.7 Exploring the challenges and difficulties of goal planning in rehabilitation for
people with acquired brain injury
Analysis of the interview transcripts revealed a number of challenges or difficulties with

the application of goal planning to rehabilitation. Some of these were associated with
achieving one or another of the intended purposes of goal planning. Most of these challenges
and difficulties could be grouped in terms of those that related to patient participation in goal
planning and those that related to goal planning within a team context. However, additional
challenges with goal planning that emerged from the interview data related to tensions that
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could arise between competing purposes for goal planning. Each of these groups of
challenges and difficulties will be discussed individually below.
5.3.7.1 Challenges and difficulties associated with patient participation in goal planning
Difficulties associated with involving patients in the process of goal planning were
divided into three groups: a) those arising from clinical factors specifically associated with
acquired brain injury, b) those arising from non-clinical patient-related factors, and c) those
arising from contextual factors associated with the rehabilitation environment or a patient’s
social environment.
5.3.7.1 a) Clinical factors specifically associated with acquired brain injury
Somewhat unsurprisingly, the interview participants in this study indicated that a

patient’s ability to be actively involved in goal planning could be substantially impeded by the
presence of communicative or cognitive impairments related to their brain injury. This
included impairments with expressive or receptive language function, memory (in particular
post-traumatic amnesia associated with traumatic brain injury), orientation, attention,
concentration or level of cognitive arousal:
Researcher: To what extent are patients involved at present?
Participant: Ah, it depends quite a lot on the client, um, like for example people
that come in PTA [post traumatic amnesia], we, we have to have their
goals done for them that first 15 days, and often they’re not oriented, or
– enough to be involved in that (Rachael)
Strategies for managing these difficulties included lowering the level of patient
involvement in goal planning while still allowing some scope for participation in the decision-
making process. For example in situations where full patient participation was not feasible
due to cognitive or communicative impairments, instead of encouraging a patient to ‘set the
agenda’ for goal planning, the clinicians reported that they might aim to just get patient ‘buy-
in’ to the rehabilitation team’s goals. Another strategy involved documenting discussions
about goals for patients who had difficulty retaining this sort of information. In situations
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where individual patients were deemed to have no capacity for making informed choices the
patients’ families were often approached to act as proxy goal planners on their behalf or, in
rarer circumstances, when a patient had no family members, the clinician selected goals
without involving the patient. For patients with some limited capacity to participate in
decision making, family members were encouraged to help set goals, with the patients being
approached to provide consent only:
Sometimes they’re not responsive, particularly if someone’s had a… big stroke –

and the whole concept of even thinking of a goal is just beyond them – so we
explain or talk with their family with them present, and we’ll say to them: this is –
you know, your family has made this decision on your behalf, what would you –
are you happy with this? (Gail)
5.3.7.1 b) Non-clinical patient-related factors
The interview participants described a number of barriers to patient involvement in goal

planning that they attributed to the patients’ behaviours and personality characteristics. Some
patients were described as having very limited or no desire to become actively involved in
their rehabilitation and were viewed by the interview participants as performing substantially
below their potential in terms of their ability to participate in the decision making. A few
interview participants (those who were working in inpatient settings) questioned whether
every patient admitted wanted to even receive rehabilitation services, raising doubts about the
appropriateness of these referrals. Others commented on the belief that certain patients
tended to adopt an ‘illness role’, which they felt made it difficult to engage the patient in goal
planning. These personality characteristics and behaviours were framed as innate to
individual patients and therefore difficult to influence:
We’re getting patients over that don’t even really want to be there, um, so how we
are going fit goals to patients that don’t really want to be able to achieve anything,
don’t want to do anything? (Frances)
Alternatively, some of the interview participants attributed difficulties with patient

participation in goal planning to the patient’s emotional responses to their situation. It was
identified that some patients had not necessarily adjusted to the experience of surviving a
potentially life-threatening illness or injury, or to the knowledge of having a newly acquired
disability when they were first admitted to the rehabilitation service. Therefore, discussions
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with these patients about anticipated outcomes seemed at times awkward and premature.
Coupled with the patient’s lack of clinical knowledge about the consequence of acquired brain
injury, many patients were labelled as having ‘unrealistic expectations’ for therapy or ‘lacking
insight’ into their situation. Consequently, the heath professionals found it challenging to
allow these patients control over what goals were set.
Other emotional consequences of acquired brain injury, such as depression, were

considered to have a direct influence on a patient’s willingness to engage in goal setting. One
interview participant suggested that some patients actively avoided discussing goals with their
clinicians, as these types of interactions ultimately required them to confront the possibility of
irrevocable loss of their previous functional abilities and old lifestyle:
I think if somebody is depressed… yep, that’s, that’s a real biggie, um – I think if

somebody - you know, the denial thing… if I don’t say any goals, then I don’t have
to acknowledge that I can’t do that anyway (Sue)
Interestingly however, this was one circumstance in which Sue believed that discussions
with patients about goals and goal planning could be used for the purpose of ‘directing
rehabilitation processes’. For example, it was suggested that discussions of goals could be
used to confront patients about their expectations or lack thereof. Sue illustrated this with an
account of suggesting an intentionally unachievable goal in order to attempt to provoke
communication with a patient who had otherwise resisted engaging in the goal selection
process. For Sue, this was part of her role to establish a ‘working relationship with patients’:
You know, if someone won’t give me anything, I’ll kind of like purposely give
them a goal that’s not really achievable and all the reasons come out why it’s not
achievable, and we get back down to it, yeah - and we can start working together
again (Sue)
Also under the heading of ‘non-clinical patient-related factors’ were sociocultural

characteristics that influenced a patient’s understanding of and beliefs regarding the value of
goal planning. The interview participants in this study identified that patients did not enter
rehabilitation with the same understanding of goals as that of the clinical team. In extreme
circumstances, when a patient’s sociocultural background differed substantially from that of
the clinicians, it was considered almost impossible to develop a shared understanding of goal
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planning at all, resulting in the heath professional feeling unable (or perhaps reluctant) to
involve the patient in clinical decisions:
You get the vagrant that’s found under a bridge, having been hit over the head with
a hammer… um, what were his skills before hand? What’s going to be his future
other than nurture and comfort? (Philippa)
5.3.7.1 c) Contextual factors
A range of different contextual factors also appeared to create challenges or difficulties

with patient participation in goal planning. Frequently identified were barriers relating to
time and resource constraints within the rehabilitation workplace. The interview participants
believed that to do goal planning well, sufficient time was required in order to get to know the
patient, their family and social environment, to develop rapport with the patient, to allow the
patient to learn about their disability and for the patient to express their perspective fully.
Restrictions on time (due to prioritisation of other clinical activities, emphasis on discharging
patients from hospital beds, or reductions in staffing levels) were reported as negatively
impacting on the goal planning process in this regard. Similarly, in situations where
significant staffing shortages were felt to exist, lack of time available to provide appropriate
levels of therapy towards the patient’s goals inhibited the perceived relevance of these goals.
For one interview participant, this made the clinical work demoralizing:
Also time constraints - we’re so short staffed that we’re just skimming the surface
and not really rehabbing, it’s more of the discharge planning – from a functional
OT [occupational therapy] point of view… as soon they’re coming over we are
having to get rid of patients so that we can like fill up the beds, so we’re not really
sort of achieving those goals that patients want to achieve (Tracey)
Also expressed by participants were concerns that the professional rehabilitation

environment created its own barriers to patients becoming more involved in goal planning.
Some interview participants commented on the ‘jargon’ that was associated with goal
planning, referring to the perceived need for goals to be expressed in a particular way (e.g. as
‘SMART’ goals). Other comments concerned the possibility that clinicians might impose
their own values on patients when attempting to work with them to set goals. As suggested
earlier, this feeling was particularly acute when patients came from socioeconomic
backgrounds that differed from those of the clinician:
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Its hard, goal setting, not to kind of put your values on you know them, it’s
important to us that we have shelter and you know, but maybe it’s not important to
someone else (Rachael)
In part, the possibility of imposing values on patients related to conflict that could occur
between a belief in the need for patient participation in clinical decision making and other
perceived professional obligations, such as a belief in the responsibility of the clinicians to
‘fix’ a patient’s disabilities. For example, Anna stated that part of the nurse’s role in
rehabilitation was to ‘push’ patients towards achieving goals related to their functional
abilities, with the quality of the patient-therapist relationship influencing how far a clinician
could push the patient. Other interview participants expressed concerns about this type of
thinking however; believing that it would be preferable for goal planning to be used to guide
rehabilitation towards approaches that better matched the values of the individual patient:
I think [it’s] one of those things that just kind of gets overlooked – kind of like,
right I’m the therapist, how am I going to fix this person, rather than how would
this person like to be fixed – if that makes sense (Tracey)
Not all of these contextual factors however related solely to the rehabilitation
environment and the values and perspectives that clinicians brought to it. The patient’s social
context, notably the involvement of family members in rehabilitation, was also reported as
creating its own challenges. As previously discussed, while the interview participants
identified that family members could facilitate greater patient involvement in goal planning,
families were also considered to have the potential to disrupt the working relationship
between the patient and the clinician.
The interview participants recognised that family members brought their own opinions,
expectations and ambitions to the rehabilitation process, and that these may be influenced by
their own emotional responses to the patient’s injury, illness and/or disability. Just as for
patients, family members were considered capable of having ‘unrealistic expectations’,
although equally the interview participants identified that some family members appeared to
regard clinicians as having expectations that were too low. For the interview participants, this
type of response to goal planning occurred when family members had not yet fully understood
or accepted the situation that a patient was in. In these circumstances, instead of focusing on
goals that the interview participants considered relevant to the patient’s current clinical
condition, the family members tended to fixate on full restoration of the patient to their pre-
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injury abilities. This, in itself, introduced questions about the clinician’s responsibility to
provide counselling to the family members as well as to the patients in their service, but more
concerning to the interview participants was the possibility that the families’ expectations of
the patient might negatively influence their clinical outcome.
It was suggested by some interview participants that this problem could occur in
situations where family members imposed their own goals for a patient, when these were
different from the goals negotiated between the patient and the clinician. In addition to
concerns that a patient might end up pursuing goals that were of limited clinical value, it was
also noted by one interview participant that the imposition of a family member’s goals might
negatively influence the working relationship between the patient and their therapist:
Often goals have been set that are totally unrealistic um because a family member
has wanted them to be goals, and they’ve pushed the client to have that as a goal,
and it’s, it’s been actually quite detrimental in a lot of times… what happens is that
the mother [of one particular client] gets very very scared because the goals now
are um - they’re much more smaller goals, they’re smaller steps, and they’re -
they’re much more realistic, ok… and I think that scares her because she thinks the
goals um for her daughter are not for the daughter that she used to know… yeah,
so that actually has been very very detrimental because um, you end up - well, I
think the client ends up being piggy in the middle (Sue)
In a similar vein, another interview participant described a case where she had
fundamentally disagreed with a family member’s interpretation of what a particular patient
had wanted from rehabilitation. When a conflict of this nature occurred between the goals of
a patient and the goals of family, the interview participants indicated that they believed their
first priority was to support the patient’s wishes, or as one participant put it: ‘if we are going
to be advocating for anybody its going to be for the client’ (Erin).
You get occasional family members – like we’ve had one now who doesn’t want
her husband to be in rehab, but he wants to be there, but he can’t speak at all, and
can’t communicate, um, and so she’s saying he wants to go home, oh, he really
wants to go home… but he’s indicated on – like through communication pictures –
a number of times that he really wants to stay in therapy, um, so in some cases I
think it’s almost a case of getting, trying not to involve them too much, because
they can, they kind of try and turn things their own way (Tracey)
As suggested in the above example, one solution for managing these types of problems
might be to limit the involvement of family members in the goal planning process. However,
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this solution assumes that the clinician is fully aware of the family’s influence on a patient’s
participation in goal planning. It was suggested by the interview participants that family
members might not always disclose their own agenda to the clinicians, so differences of
opinions regarding expectations for the patient might not necessarily be open for discussion.
Clinicians may not even know if a family member has had an influence on the goal planning
process:
Because a family member goes in and they change them [the goals], and they talk
to them [the patient], and they’re working on something completely different, and
the whole programme’s changed – you may know about it, you may not (Sue)
Despite these reported difficulties, the majority of the interview participants stated that
family involvement in goal planning was not usually a problem. The interview participants
reported that most often family, patients, and clinicians do agree on the goals that are set.
While the clinicians at times questioned the benefit of involving family in goal planning, they
did concede that family members themselves frequently wanted more information about the
patient’s situation and appreciated greater involvement in rehabilitation planning:
I just don’t know how beneficial [involving family more in goal planning] would
be actually -ah, I think they would really appreciate involvement in some way, um,
we get a lot of families saying that you know they don’t feel like they in regular
contact with the therapists, and they would like more -um, but once again I think
it’s the balance. (Rachael)
5.3.7.2 Challenges and difficulties with goal planning in a team context
As noted in Table 7 (p.103), one important part of the value that the interview
participants attached to goal planning related to a belief in the positive effects that goal
planning could have on teamwork in clinical rehabilitation. However, equally prevalent was a
belief that some degree of good teamwork was required before effective goal planning could
be achieved (as opposed to effective teamwork simply resulting from the goal-oriented
processes). Consequently, challenges and difficulties with goal planning were reported to
arise when problems with collaborative teamwork occurred. Examples of such problems
included differences of opinion regarding the value of goal planning, differences in the
prioritisation of goal planning activities, limitations on the ability of busy team members to
meet together as well as problems with communication within the team:
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So the teamwork does need to come first, before you set the goal, yeah… you
know, making sure you having regular meetings, that you’re communicating, and
um, and I think what can happen sometimes is that you can set a goal together with
a client… something changes in that goal, and then you don’t get the
communication that that’s now changed or something, so yeah, you actually have
to work really, really hard as a team when you’re working on joint goals… (Sue)
Often the concept of a ‘joint’ goal or ‘interdisciplinary goal’ (the antithesis of this being
a ‘single-discipline’ or ‘discipline-specific’ goal) was used to indicate when a team approach
to goal planning had been effective. ‘Joint’ goals were characterised by the requirement for
more than one clinician to be involved in the selection of a goal and in the therapeutic
activities needed to achieve the goal. It was also suggested that ‘joint’ goals tended to focus
on outcomes that were more personally relevant to the patient. Rachael suggested that when
goal planning occurred without intensive team discussion it felt less clinically relevant and
more of a bureaucratic exercise (i.e. ‘just a process that needs to be done’). It was also
reported that while collaborative approaches to goal planning were considered the ideal, there
was a strong tendency for teamwork to ‘regress’ back to ‘single-disciplinary’ goals. Again,
the suggestion was that ongoing work was required in order to maintain a satisfactory level of
collaborative goal planning:
We try not to have too many um discipline-specific goals… [but]… there’s a

tendency to move back towards that, and that needs to be continually kind of
worked on, and remind that – and sometimes you go hang on a minute here we are
we’ve got all these discipline ones again, we need to go back and review it…
(Erin)
In addition to the time and shared values required for team approaches to goal planning,
the interview participants also identified that clinicians needed to be able to agree on the most
appropriate direction for an individual patient’s rehabilitation. This required clinicians to
have some baseline level of shared beliefs about pathology, prognosis and relevant treatment
options as well as some capacity to productively settle disagreements on these topics. As a
consequence, it was suggested that clinicians might even be selective regarding whom in their
team they collaborated with, orienting their work towards colleagues who shared similar
views and avoiding those who did not:
It is really, really hard when you’re working with another colleague… and you just
don’t see eye to eye… with what is a realistic goal, you don’t see eye to eye with
planning your interventions around each other, yeah, yeah - that is really hard, and
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I think probably in our team we do pick and choose who we kind of work with
(Sue)
Another reported difficulty with team approaches to goal planning was that team
members had different levels of knowledge or understanding about goals and goal planning.
There was a commonly held belief that some professional groups were generally better at goal
planning than others. In particular, occupational therapists, physiotherapists, and speech
language therapists were considered to have more training in goal planning, and therefore
tended to be better able to conceptualise rehabilitation activities in terms of ‘patient goals’.
Nurses, doctors and social workers on the other hand were often attributed with confusing
clinical tasks and clinical outcomes when setting goals:
I think what has been noticeable is a difference between how therapists think and
how other health professionals think, so… tarring everyone with the same brush -
social worker, doctors, and nurses have real problems with goal setting, because
they are much more, or appear to be much more concrete thinkers, and are real
process-orientated people, so like the [assessment] form needs completing and the
catheter needs to come out, and the diagnosis – whereas I think therapists can see,
or seem to be able to articulate the bigger picture, so you know it isn’t that the
catheter needs to come out, it’s that we’re looking at continence coming right,
something around that (Danielle)
Interestingly, this belief regarding the nurses’ perspective on goal planning was
reinforced by the opinions of one of the nurses, Anna, interviewed for this research:
Researcher: What’s an example of a nursing goal?
Participant: Nursing goal, um, could be as simple as you know, retraining the
bladder, ok, our goal this week is to remove the catheter, and two hourly
toileting till you’ve got all that regime sorted out (Anna)
In comparison however, the second nurse participating in this study, Gail, was quick to
draw a very clear distinction between clinical tasks and clinical outcomes. Gail also
emphasised that she ensured she provided education on this distinction in staff training for her
unit. This difference between the perspectives of Gail versus those of Anna appeared to
highlight a possible distinction between novice and expert approaches to goal planning. Gail
was clinically more senior and had postgraduate qualifications relevant to clinical
rehabilitation. This again suggested that goal planning is a learned skill and one that
improves with knowledge and experience.
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Anna’s interview also highlighted some of the difficulties with communicating goals to
every member of a rehabilitation team. Processes might be in place for establishing and
documenting team goals, but this did not necessarily mean that everybody in the team felt
oriented towards these team goals or even understood what these goals were. It is possible
therefore that instead of being the process which binds a team together for interdisciplinary
rehabilitation, goal planning could be viewed as more of an activity that was restricted mainly
to the work of allied health professionals:
We’re all working for the same sort of thing… but at times I can’t see what the
others are working for, you know? (Anna)
5.3.7.3 Challenges and difficulties arising from tension between conflicting goal purposes
Finally, challenges and difficulties also appeared to arise from conflicts between
competing purposes for undertaking the goal planning. So for example, using goals for the
purpose of maintaining a patient’s ‘hope’ or for ‘building a working relationship with
patients’ appeared at times to conflict with other purposes for goal planning, such as
‘evaluating progress and outcomes’ or ‘building a team approach’. Tracey illustrated this
with a case involving a man who had developed aphasia following a stroke. When, after a
period of therapy, there was very limited restoration of this man’s expressive communication,
the team, along with Tracey, decided the rehabilitation should progress onto compensation
techniques (such as the use of a communication board) rather than on the retraining of speech.
The patient however strongly desired to continue with speech retraining, and Tracey was
supportive of this to an extent. This was because she believed the patient had a right to hope
for further improvement but also because she believed that working a little on the patient’s
goals was important for her to ‘build a working relationship’ with the patient, allowing her to
continue to introduce the compensatory strategies that the rehabilitation team believed
necessary. The conflict between purposes for the goal planning arose when the interview
participant received negative reactions from within her team when she suggested continuing
with speech retraining. As a result, she ended up with one set of goals, which she discussed
with the team and documented in the team’s goal plan, and a second set of goals, which she
kept between herself and the patient:
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I think it makes me feel a little bit like a positive little - little underground
operation’s going on, and I’m kind of trying to work towards that patient thing – I
still have a little bit of hope for that patient, but I don’t want to talk to the doctor
about it, because I can’t be bothered having him tell me, oh you’re never going –
which is what happened, you know, I say, well [the patient’s] got four spontaneous
words now… and the doctor’s like, “well, so what. I can say ‘fish and chips’, what
does that mean? Nothing” – and I’m like, well if that’s what’s your attitude going
to be, I’m not going to talk to you about it, we’ll just keep working away at it by
ourselves, and it’ll keep him happy, and it’ll make me feel that I’m doing
something that make’s him happy while working away at something functional
(Tracey)
Frequently, as described above, the solution to such conflict between goal purposes
involved the development of more than one set of goals, with different sets of goals involving
input from different groups of people, and different goals being documented in different
places and in different ways (or sometimes not being documented at all). Another example of
this was in the use of goal planning in order to ‘meet contractual expectations’. Here, the
documentation of goals was reported as needing to be in a style that addressed the
expectations of funders: in other words, presenting a plan succinctly, with objective,
measurable, time-limited goals. As this approach did not address all the desired purposes of
goal planning, separate sets of goals were reported as being created in order to meet the
additional needs of the patient and the rehabilitation team:
Participant: When a new patient comes in we um put together their rehab plan…
yeah, it’s easier if we do the rehab plan goals first, then we can kind of
like cut and paste into the other one [the report for ACC], but – it doesn’t
always work out that way… in the ACC report we pick out the most
relevant sections and put them in, like it’s not relevant to have family
goals a lot of the time –
Researcher: Oh, so not relevant to ACC?
Participant: Yeah, it just doesn’t seem to be as relevant to put those family – like
social interaction goals in
Researcher: Why, why doesn’t it seem as relevant?
Participant: I’m not sure, I mean I suppose it is because ACC is so kind of outcome
focused, and – yeah, they can be harder to measure – (Rachael)
Rachael later on went on to suggest that it might be beneficial to develop a third set of
goals in order to maximise ‘motivating’ effects and ‘building a working relationship’ with the
patient. She identified that goals for these purposes needed to be in a language that the
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patient could understand and presented in a manner that maximised patient involvement, with
perhaps fewer goals being presented to the patient than documented for the team or the health
funder.
Goal planning within the context of health funding was also described as lacking
flexibility: once goals were documented for the purpose of ‘meeting contractual requirements’
they were then considered difficult to alter. This made it harder to use goal planning to ‘build
a working relationship’ with patients, where ideally goal planning could accommodate a
patient’s changing circumstances or perspectives. Sue put it this way: ‘…the more we get to
know somebody, the more those goals change’.
[When goal planning] was ACC driven, and um, yeah…you had written those
goals down and it was almost like a week later you might have regretted it slightly
and wanted to change it or it wasn’t quite right, but you kind of knew you had set
on a certain path with someone, yeah – so I guess it’s, it’s feeling a little bit
restricted as a therapist that you can’t actually - yeah, be flexible with someone,
and change things (Sue)
Other conflicts existed with using goal planning for the purpose of ‘evaluating
outcomes’. The feeling was expressed that, regardless of other intentions, if a clinician
documented one goal as the objective of rehabilitation they would want to achieve that goal.
This was because the achievement or non-achievement of goals was seen to reflect on them
and their clinical work. Thus, it appeared that using goals to evaluate the quality of
rehabilitation could unduly influence the goal planning process for other purposes. For
example, if using goal achievement to demonstrate their clinical effectiveness, clinicians
might be less inclined to agree to goals that a patient chose (using goal planning for
‘enhancing self-determination’) or might be less inclined to stop pursing goals that were no
longer clinically relevant or meaningful to the patient.
The interview participants also reported a risk associated with goals when one purpose
dominated the goal planning process. In this circumstance the documentation of goals
became more like a bureaucratic exercise; one which was expected of the clinician but which
became increasingly irrelevant from a clinical perspective. An example of this was provided
by Sue, who suggested that at times the documentation of goals for the purposes of appearing
‘client-centred’ seemed to be more important than using goal planning to direct the
rehabilitation towards outcomes that were best for the patient. Again, this concern related to
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the belief that good goal planning practice required time to get to know the patient and
flexibility to adapt to the patient’s evolving needs. In her service however, goals were
expected to be documented very soon after admission to the service, and clinical notes were
audited to check that this expectation was being met:
Participant: You know people come into like ward situations or we when we go out to
see them in the community, and we’re asked on that first visit to write down
three goals for them, isn’t that crazy…?
Researcher: Do know where the pressure for that comes from?
Participant: I think it’s to show that we’re a rehab service and we’re client centred (Sue)
5.4 Discussion
The aim of this study was to use inductive research methods in order to explore how
clinicians talk about the application of goal planning in rehabilitation for people with acquired
brain injury. In general, the clinicians interviewed considered goal planning important for the
delivery of quality rehabilitation services, although for some, the exact reason why goal
planning should be valued was unclear. There was also some indication within the clinicians’
talk that further clarification of the concept of a ‘goal’ was required, with particular need for a
distinction to be drawn between the construct of a ‘goal’ as it is applied in a rehabilitation
context and the broader psychological concept of goal-directed human behaviour.
It may be tempting to think that this finding reflected some lack of understanding about
goal planning within the population of clinicians interviewed for this study. After all,
previous attempts have been made in published literature to establish working definitions of
terminology related to goals and goal planning (Wade, 1998, 1999c) or to promote
taxonomies for the categorisation of different types of goals specifically related to brain injury
rehabilitation (Kuipers et al., 2003; Simpson et al., 2005). However, what this study
demonstrates, and what has perhaps been glossed over in previous literature on this topic, is
that the term ‘goal’ has been used to refer to not one but many concepts within the
rehabilitation environment. These include (but are not limited to): an individual patient’s
hope or desire, the therapeutic objectives of individual clinicians, the shared objectives
negotiated between any number of stakeholders involved with an individual patient’s
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rehabilitation, a point of reference for outcome evaluation, as well as in some cases a

statement of intent for accountability to a health funder. Consequently, what is now needed is
for the discussion around goal planning terminology to progress from agreement at the level
of individual rehabilitation services (Kuipers et al., 2003; Wade, 1999b, 1999d) towards a
more international-level consensus. A model for the development of this type of
international-level consensus is the work that has occurred around shared terminology related
to disability and functioning, which resulted in the ICF (World Health Organization, 2001a).
Regarding goal planning, such consensus development might include agreement of terms to
discriminate between the different meanings associated with the word ‘goal’ as well as
operationalisation of key characteristics that can be used to describe and differentiate between
different approaches to goal planning. An internationally-shared lexicon related to goal
planning in rehabilitation would be useful for enhancing communication within and between
rehabilitation teams and professional groups as well as for addressing previously identified
problems with comparing or reproducing research into the effectiveness of different
approaches to goal planning in rehabilitation (c.f. Chapter 3). Finally it would facilitate
clinical trials of different approaches to goals planning within rehabilitation, by more clearly
defining the intervention.
The results from this study also offer further explanations as to why problems with goal
planning sometimes occur when applied to socially complex environments such as the
rehabilitation of people with brain injury. The findings from the review reported in Chapter 2
suggested that different purposes for undertaking goal planning may require different methods
for implementation of best practice. What this current study suggests is that different reasons
for undertaking goal planning can both interrelate and conflict. So, for example, in addition
to previous explanations for difficulties associated with involving patients in goal planning
(Baker et al., 2001; Conneeley, 2004; Parry, 2004; Playford et al., 2000; Wottrich et al., 2004;
Wressle et al., 1999), the findings from this study suggest that problems can arise when goal
planning for patient-related purposes conflicts with other reasons for applying goal planning,
such as to provide accountability to a health funding agency. For similar reasons, while goal
planning has previously been described as ‘a prerequisite for interdisciplinary teamwork’
(Schut & Stamm, 1994, p. 223), this study suggests that conflict (both overt and covert) can
occur when members of the rehabilitation team have different opinions about what the point
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(or primary purpose) is for having goals for individual patients. While further research is
required into goal planning best practice, individual rehabilitation teams may gain immediate
benefit from discussing and agreeing on the primary purpose (or purposes) of goal planning in
their service or from debating such issues when conflict arises during the management of
individual patients. Considering the range of purposes currently associated with goal
planning in rehabilitation, it may be an appropriate response to have more than one set of
goals for individual patients, as was apparently the case in some of the accounts given during
interviews for this study. However, if services are to have multiple sets of goals for
individual patients, it might be best to do this intentionally and explicitly.
There are some limitations to results from this study arising from its scope and the
methods that have been used. It is important to recognise that this study investigated what
clinicians said about the application of goal planning in their work environment, not
necessarily what they did. This is in no way intended to suggest that the clinicians were being
disingenuous; merely that the data collection in this study was based on the clinician’s
recollection, self-reflection and interpretation of past clinical events, and therefore
representative of this type of perspective. In the following chapter, this issue is addressed by
investigating goal planning in rehabilitation with methods that place greater emphasis on data
collection based on observation of actual clinical practice, rather than on reported experiences
or opinions. Given that goal planning for people with brain injury often occurs within a team
context, and given the nature of the findings from this study, it would seem that observation
of team activities related to goal planning is warranted. The following study in Chapter 6 also
includes investigation of how the agendas of multiple stakeholders (e.g. the patient, their
family members and the individual clinician involved) are managed during the process of goal
planning, and how these agendas change or do not change over time.
Another limitation of this study was that the study group did not include any physicians.
Given that physicians are core members of any rehabilitation team, and given that some
participants expressed concerns regarding the involvement of physicians in goal planning, it
would have been beneficial to have included a few physicians in the study population. Again,
this issue is rectified in the study presented in Chapter 6, with the inclusion of a number of
physicians in the collection of both observational and interview data.
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As with constructivist grounded theory methodology, the purpose of this current study
was not to make generalisations about goal planning in rehabilitation, but instead to develop
plausible accounts that are relevant to the development of theory in this area of study
(Charmaz, 2006). However, it is worth noting that the clinicians interviewed for this study
were all working within a New Zealand context. These results may not therefore reflect the
experiences or perspective of people working in brain injury rehabilitation in other countries,
in particular those countries where no funding requirement exists for implementation of goal
planning. It was also assumed for this study that the gender and ethnicity of clinicians was
not a relevant factor when selecting people to participate in interviews for data collection. A
follow up study would be required to specifically explore this issue.
Further discussion of the findings from this study, in conjunction with discussion of the
other work presented in this thesis, is provided in Chapter 7.
5.5 Conclusion
The terms ‘goals’ and ‘goal planning’ appear to have multiple meanings and purposes
within the context of rehabilitation for people with brain injury. Whilst there was an overall
positive view about the benefits of goal planning, there also appeared to be a lack of clarity
regarding the exact value of goal planning in rehabilitation and this contributed to tensions
within the clinical environment. The analysis from this study has offered an overview of the
key interactions between different purposes for undertaking goal planning, which may be
useful to rehabilitation teams who wish to analyse the application of goal planning in their
own work environment. Further research is required to investigate what does happen in
clinical environments around goal planning and to explore goal planning from the
perspectives of other stakeholders, including patients and their families, and to investigate
how the application of goal planning changes over time for individual patients with brain
injury. These issues will now be explored in the following chapter.
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Chapter 6: Privileged versus patient-centred goals in inpatient stroke rehabilitation
Chapter 6: Privileged versus patient-centred goals in inpatient

stroke rehabilitation: a grounded theory investigation
6.1 Introduction
In this study I sought to use grounded theory in order to explore how goal planning was
applied to a series of cases of interdisciplinary rehabilitation for people with stroke, and how
goals and goal planning are conceptualised by the various stakeholders involved (e.g.
clinicians, patients and their family members). Many of the previous qualitative
investigations into goal planning in rehabilitation, including the one described in Chapter 5,
have been based solely on data collected via semi-structured interviews (Conneeley, 2004;
Holliday, Ballinger et al., 2007; Lawler et al., 1999; McColl et al., 2000; Melville et al., 2002;
Playford et al., 2000; Schulman-Green et al., 2006; Wottrich et al., 2004; Wressle et al., 2003;
Wressle et al., 1999). For one of these investigations, it was reported that the researcher
supplemented interview data with field notes from observation of clinical practice
(Conneeley, 2004), but in this case, this additional information was used to inform the
analysis of interview data, rather than as separate data in its own right. In the literature
reviews undertaken for this thesis, I identified only one study in which observational data
were used in a qualitative investigation of goal planning in a rehabilitation context (Parry,
2004). In this study, conversation analysis was employed to explore video-recorded clinical
interactions between physiotherapists and their patients. (The findings from this study have
already been summarised in the introduction to Chapter 5.) It would appear therefore that no
qualitative study has yet been undertaken into the application of goal planning in
interdisciplinary rehabilitation that has included the collection of observation data from actual
clinical cases. The study described in this chapter addresses just this issue.
There are some advantages to employing a more observational-based data collection

method. Firstly, this approach would allow for the specific analysis of how goal planning is
applied to individual cases of rehabilitation. In other words, in comparison to asking
clinicians to comment in general about goal planning in rehabilitation, this method focuses
more intensively on the idiographic. Different perspectives (those of patients, family
members, and various clinicians) can thus be investigated with reference to the same specific
145
episodes of goal planning or goal use, rather than making assumptions about different
perspectives from interviews based on generalised open-ended questions.
Secondly, this method provides a unique way to investigate the application of goal
planning to rehabilitation for people with severe cognitive and communicative impairments.
These people have previously been excluded from qualitative studies into goal planning, as
they have not been able to participate in interview-based data collection (Conneeley, 2004;
Holliday, Ballinger et al., 2007; Melville et al., 2002; Schulman-Green et al., 2006; Wottrich
et al., 2004; Wressle et al., 1999). An observational approach to studying goal planning
allows for the inclusion of data related to the development and use of goal planning for people
with dysphasia or cognitive deficits. This is an area of particular interest as it has previously
been described as problematic by clinicians working in rehabilitation (Conneeley, 2004;
Playford et al., 2000), including those interviewed for the study in Chapter 5.
Thirdly, a qualitative study based on collection of data around individual cases also
allows for the observation of goal planning as it evolves over the course of a patient’s period
of rehabilitation. Thus, the way goals are developed and changed over time can be analysed
and reflected upon. This longitudinal approach to data collection is also consistent with a
constructivist application of grounded theory, as it supports the development of stronger
relationships between the researcher and the study participants during the process of data
collection and analysis, and thus greater opportunities to explore the construction of theory
grounded in data relevant to the participants’ lives (Charmaz, 2006).
Because of this idiographic emphasis, the study presented in this chapter has a more
specific focus than that of the study described in Chapter 5. In order to concentrate more
intensively on a set number of clinical cases, I chose in this instance to limit my investigation
of goal planning to just inpatient rehabilitation for people with stroke. In other words,
perspectives on goal planning related to rehabilitation for people with traumatic brain injury,
or other types of brain pathology, have been excluded from the scope of this investigation, as
has the application goal planning to outpatient or community-based rehabilitation.
There are some challenges associated with attempting to observe goal planning in
interdisciplinary environments however. Information from my previous study appeared to
suggest that not only does goal planning and goal evaluation occur in formally scheduled
146
meetings (such as in initial interviews with patients and in IDT meetings), but also in passing
discussions in hallways, around the nursing station, and during staff breaks. Likewise,
conversations about goals could reasonably be expected to arise in any interaction between a
patient, their family, and clinicians. For this reason, the intent of collecting data for this study
was not to gather all instances where discussions of goals relating to a specific case occurred,
but rather to gather a wide range of examples of such instances. To this end, purposeful and,
later, theoretical sampling were used to select which clinical sessions or meetings to observe,
which participants to interview, and when.
In comparison to the study presented in Chapter 5, this study was much larger
(generating more data) and more complicated (requiring multiple strategies for the
recruitment of participants and for the collection and analysis of data). The method for this
study, presented below, is therefore more elaborate than that presented for the study in
Chapter 5.
6.2 Method
6.2.1 Research design
This study employed constructivist grounded theory (c.f. Chapter 4) in order to

investigate the application of goal planning to interdisciplinary inpatient rehabilitation for
people with stroke. As described above, this study focused on goal planning as it was applied
to a specific selection of clinical cases. For the purposes of this study a ‘case’ was deemed to
be an episode of inpatient rehabilitation for an individual patient who was admitted with a
primary diagnosis of stroke. In order to fully explore each case, data on goal planning were
gathered from multiple sources including, not only interviews with patients, their family and
health professionals, but also audio-recordings and observation of interactions between
patients, family and clinicians; audio-recordings and observation of IDT meetings; field notes
from observation in the ward, and from documentation in the patient’s clinical notes. A
Regional Ethics Committee gave approval for this study to be conducted.
147
6.2.2 Participant selection and recruitment
Clinical cases for this study were selected from two publicly-funded, geographically-
separate inpatient services with specialist skills in the provision of interdisciplinary stroke
rehabilitation. Initially, these services were approached via the service manager and invited to
participate in the study. Information sheets on the study were provided to clinicians working
in each IDT and were supplemented by presentations to each team on the objectives and
nature of the study to be undertaken. In both hospitals, multiple presentations on the research
were provided for the pragmatic reason that different professional groups (the nurses, the
allied health staff, and the medical staff) tended to be available at different times. I spent
additional time on each ward developing rapport with the unit staff before beginning
participant recruitment.
A separate information brochure explaining the study in lay terminology was tailored
for patients and their family members. Patients were eligible to be included in the study if
they were receiving inpatient rehabilitation for issues primarily related to stroke. The severity
of the stroke (including severity of any cognitive or communicative impairments) or the
duration of time since the first onset of stroke were not reasons for exclusion from the study,
although entry into the study was required to coincide with a new episode of inpatient
rehabilitation.
Patients who met the study’s inclusion criteria were initially identified and approached
by staff from the IDT before I visited them to discuss whether or not they wished to
participate in the study. Purposeful sampling was used to select individual cases in order to
ensure that the study group included patients from a range of different backgrounds.
Particular attention was paid to including both men and women, people from different age
groups, those with very severe impairments following their stroke as well as those with less
severe impairments, and finally to include people from both European and non-European
ethnicities. Theoretical sampling was used for selection of the last few cases in the study in
order to recruit participants with whom I could most efficiently explore the relationships
between the core concepts emerging from the data.
Patients were required to provide written informed consent before any data were
collected about them. If there was any concern about a patient’s capacity to do so, due to
148
severe cognitive or communicative impairments for instance, the patient’s next-of-kin was
approached to provide written informed consent by proxy. In these cases, the patient’s
physician also signed a statement indicating that the patient’s involvement in the study was
not adverse to the patient’s interests and I provided an additional statement to confirm that I
would re-approach the patient for written informed consent if they ever improved to the point
where they were able to advocate for themselves again.
As well as recruiting patients to the study, I also recruited a number of family members
and health professionals involved in each case. For any case where a family member was
actively involved in clinical discussions or decision making on the ward and/or as a support
person for the patient on discharge from hospital, that person was approached and invited to
participate in the study.
Likewise for each case, a number of clinicians were also invited to participate in the
study. There were three aspects of the investigation that the clinicians were able to be
involved in as study participants: 1) semi-structured interviews, 2) the collection of
observational data from one-on-one clinical interactions (such as patient assessments or
therapy sessions) and 3) the collection of observational data from group interactions (such as
team meetings or family meetings). To simplify the recruitment process, clinicians were
invited to provide separate consent for each of these three aspects of the study. This approach
also allowed clinicians the option of consenting to participate in some aspects of the study but
not others. Clinicians were eligible to participate in interviews or in observation of their
clinical interactions with patients or family members if they were actively involved in the
development of goals for the participating patients. However, clinicians were eligible to be
study participants for observational data gathered during team meetings simply if they
attended those meetings.
Any family members or clinicians thus recruited were afforded the same rights in the
study as the participating patients. For example, all participants were given written
information explaining the study; were given an opportunity to discuss the study prior to
agreeing to participate in it; were only involved in the study once they had provided written
consent; had data related to them treated confidentially and anonymously; and were informed
of their right to selectively withdraw from any aspect of data collection, or from the study as a
whole, at any point without consequence.
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6.2.3 Data collection
Data from within each rehabilitation unit were collected over two separate four month
periods. As described above, data for the study were collected around selected clinical cases,
from multiple sources, including both observational and interview data, with (initially)
purposeful sampling and (later) theoretical sampling used to determine which sources of data
to select for inclusion and when. For instance, I pursued opportunities for interviews with
specific clinicians or family members when it became apparent they were increasingly
involved in a particular case. Thus, while the sampling of data was informed by the concepts,
themes and ideas emerging from the study, it was also based on my observation of each case
as it unfolded. Bearing this influence of purposeful and theoretical sampling in mind
however, for each case a common set of data was sought. A summary of this common set of
data and the approach to participant recruitment and data collection is presented in Figure 5.
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FIGURE 5: Flowchart documenting entry into the study and data collection
Patient is admitted to
inpatient rehabilitation unit
Patient and/or family
initially approached by
their health
professional who
requests verbal
approval for the
researcher to discuss No Patient continues with
Patient/family consents? normal services
participation in the
study with them
Yes
Collection of Demographic Information:
– Type and severity of stroke

– Duration of time between onset and admission to rehabilitation
– Patient age, gender, ethnicity, plus vocational and avocational factors
– List of family members involved and relationship to the patient
– List of health professionals involved in the patient’s rehabilitation
Collection of observational data: Collection of interview data:
• Observation and audio-recording of Following initial clinical meetings with the

interactions between individual clinicians patient and/or family members:
and patients and/or family where goal
• Audio-recording of a semi-structured
planning may be discussed, including:
interview with patient and/or family
– The first scheduled meeting with the • Audio-recording of interviews with a
patient to discuss inter-professional selection of 1-4 of the health professionals
(team) goals or profession-specific goals involved in the patient’s rehabilitation
– A sample of scheduled therapy sessions,
particularly in the early phases of
rehabilitation In the latter stages of the patient’s admission
• Observation and audio-recording of any team (based on average length of stay and
meeting where the participating patient is anticipated discharge date)
discussed
• Observation and audio-recording of any • Audio-recording of a second semi-structured
family meetings where discussion of interview with the patient and/or the family
planning, progress and/or discharge is • Audio-recording of a second semi-structured
intended to occur interview with clinicians previously
• Collection of documented goals or reference interviewed or other clinicians who became
to goals from the patient’s clinical notes involved in the case in the latter stages.
• Documentation of field notes based on
observation in the unit and review of the
patient’s medical file
Patient discharged
Audio-recording of a third semi-structured

interview with patient and/or family three to four
months following discharge 151
All interviews followed a semi-structured, open-ended format. An iterative approach

was taken to the selection of topics for each interview. The first interview schedules however
began with very broad questions related to the process of goal planning in rehabilitation for
each specific case. Clinicians were asked about how goal planning had progressed for the
patient, what had been learnt and how this information was going to be used. Patients and/or
family members were asked questions about their experience of being in the rehabilitation
unit, how they had been involved in clinical decision making, how the goal planning process
had gone for them, what their perspective was on their future, and what their objectives were
for the future (see Table 8 for further details regarding the initial interview schedules).
As the study progressed, and following the constant comparative method of grounded
theory (Charmaz, 2006), the selection of interview questions was informed not only by ideas,
concepts and themes emerging from analysis of earlier data, but also in response to events
observed and opinions elicited during each case as it unfolded. Participants were asked to
comment on events related to goal planning that had transpired during individual cases,
allowing for more detailed exploration of these issues.
All interviews in hospital occurred in a private room, either in a single-bed cubicle or an

interview room on the ward. Interviews with patients and/or their family members following
discharge from hospital, occurred in a place of their choosing. Mostly this involved
interviewing people in residential facilities or in their own homes.
A total of 27¾ hours of audio-recorded data were collected during the study. This
included 14¼ hours of observational data and 13½ hours of interview data. On average, each
case involved the collection of one and half hours of audio-recorded observational data, and
one and half hours of audio-recorded interview data. However, the amount of data collected
depended largely on the complexity of each case and the duration of the patient’s stay in
hospital. One patient, who had the shortest length of stay, remaining in the rehabilitation unit
for less than one and a half weeks, had only one hour of data collected about him, most of
which consisted of interviews with the patient himself. At the other extreme, another case
involving a patient with a severe stroke, whose progress was very limited, accumulated five
and a half hours of data audio-recorded data; consisting of four hours of observational data
and one and a half hours of interview.
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TABLE 8: Initial interview schedules
Initial interview schedule for health professional:
Tell me about the initial goal planning for [the patient]?

What do you think the main purpose of goal planning for [the patient] is at this stage?
How do feel this goal planning has gone so far?
What do you think [the patient] understands about goal planning at this stage?
What do you think [the patient] is focused on at present?
What has gone well about the goal planning process so far?
What has been least satisfying about the goal planning process so far?
What new things did you learn about this case as a result of goal planning activities?
What will you do with this information now?
What will you do with the goals that have been set now?
Is there anything you would have changed about your approach to goal planning with [the
patient] in hindsight?
Initial interview schedule for the patient and/or their family/whānau:
Tell me about what has happened to you [your family member] since you [they] were
admitted to this unit?
What do you hope will happen during your [family member’s] stay here?
Tell me about how the staff here have involved you in planning for your [family member’s]
rehabilitation? How do you feel about that?
What do you think the staff here know about your own [your family member’s]
goals/aims/wishes at present?
How do you feel about your involvement in the decisions that are being made at present
about you [your family member]?
Why do you think the staff are interested [not interested?] in your goals/aims/wishes for
your [family member’s] rehabilitation?
What concerns you the most about your [family member’s] future at the moment?
Do the staff members here know this about you [your family member]?
What do you think they have done with this information? OR Why do you think they don’t
know this information? How do you feel about that?
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Audio-recorded interviews with clinicians tended to be fairly short and focused, usually
lasting around ten to 15 minutes each, although some of the longer interviews ran for up to
half an hour. Interviews with patients and family members tended to be longer, running for
20 to 45 minutes each. These interviews were usually preceded by informal conversation
around each case, allowing the interview questions to more specifically address the issues of
particular relevance to the study.
Audio-recordings were made using an Olympus DS-2200 digital recorder with stereo
recording capabilities. This digital recorder was small (about the size of a cell phone), but
had the capacity to make clear recordings of multiple speakers in one room without requiring
the speakers to wear microphones. The recording device was therefore unobtrusive during the
collection of data for the study. It also required no cassette tapes, and allowed for multiple
recordings of various lengths to be collected easily and successively.
All audio-recorded data were stored as digital files in a password-protected computer.

These audio-recordings were then transcribed verbatim. In order to protect the anonymity of
participants, pseudonyms were used in the transcriptions to replace the names of patients and
family members, professional titles to replace the names of clinicians, and descriptive phrases
to replace identifying names of places or organisations. According to the style of transcript
notation used (see Appendix 1), any such editorial alterations in the transcripts were enclosed
in square brackets, denoting where the change had been made.
Data from documented notes in the patient’s clinical file were also transcribed as they
were written, using whatever medical shorthand appeared in the original clinical file (for
example, using ‘Rx’ to mean ‘treatment’, ‘↑’ to mean ‘increase’, ‘d/c’ to mean ‘discharge’).
The only editorial alterations at this stage of data collection related to the removal of
identifying names and places, as described above.
A few clinicians refused to provide consent to participate in the study. This presented a
challenge regarding how to collect data gathered during IDT meetings when most but not all
clinicians in the meeting had agree to participate in the study. The solution to this challenge
(deemed acceptable to the participating rehabilitation units) was to audio-record all team
meetings, but to not transcribe data relating to non-consenting clinicians. Since those who did
not wish to participate in the study also did not tend to be particularly outspoken during the
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team meetings, it was a relatively simple matter to note which speakers’ contributions should
not be transcribed during observation of the meetings.
6.2.4 Data analysis
Data analysis occurred concurrently with data collection. Transcripts from interviews,
observed clinic sessions and interactions, and documentation related to goals from the patient
files were all considered equally as data for the study, and were analysed in a similar way.
All data and key field notes related to a single case were complied in one document, with
subheadings denoting the type of data and the context of its collection. The computer
software NVivo® (Version 2.0.163) was used to help organise and manage this data, as well
as any memos developed during the process of data analysis.
Coding and categorisation of interview transcripts followed the constant comparison

method of grounded theory (Charmaz, 2006). Each transcript was read and coded, with
subsequent re-reading and coding incorporating findings from additional interviews. Initial
coding (open coding) was undertaken on a line-by-line basis. The relationships between and
within categories emerging from this coding were explored with increasingly higher levels of
coding and conceptualisation. Of particular interest at this stage was analysis of what became
a goal of rehabilitation, what the characteristics of these goals were, and why. Attention was
paid to what might be considered ‘formal’ goals (goals that were documented in the patients’
clinical files) as well as ‘informal’ goals, (goals that were discussed by the various
participants as objectives or aims of rehabilitation and recovery, but not documented as such
in the clinical notes). As the study progressed, the focus in the data analysis expanded to
include coding and categorisation of what did not become a goal, and why. Also of interest,
following the findings from the study in Chapter 5, were data related to the value attributed to
goal planning in rehabilitation and the purposes to which goal planning was applied in the
clinical environment.
Data were progressively moved to more abstract levels with the identification of
emerging theoretical constructs. These were explored in more detail with the use of memo
writing and diagrams. Knowledge gained from my previous studies into this topic provided
additional theoretical sensitivity to explore the data and themes emerging from the data in
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depth. Data collection occurred until data saturation was reached; that is, until I believed that
the collection of new data would not significantly alter the construction of theory that
emerged from this study (Morse & Richards, 2002).
As for the study described in Chapter 5, debriefing with one of the thesis supervisors
after sets of interviews, as well as negative case analysis (Morse & Richards, 2002) were used
to establish the credibility and trustworthiness of the emerging theory. In addition, debriefing
with the thesis supervisors ensured that the theoretical sampling was justified and that the
decision regarding when to stop collecting data could be defended. Further, one supervisor
independently reviewed and coded 15% (just over 4 hours) of the audio-recorded data and
associated field notes, in order to ensure that the themes highlighted in the analysis did in fact
arise out of the data, instead of being imposed on it (Crotty, 1998). Review and discussion of
data with the research supervisors throughout the project also provided guidance regarding the
development of themes and identification of relationship within the data. Extracts from data
are presented (with pseudonyms) to support the findings presented in Section 6.3.
6.3 Results
From the data gathered during this study I constructed a substantive theory which linked
two core themes related to the application of goal planning in inpatient rehabilitation for
people with stroke. The first of these themes was the privileging (or prioritisation and
promotion) of certain goals within the system of inpatient rehabilitation. These privileged
goals were characterised by three attributes: an orientation towards physical function, short
timeframes, and the conservative estimation of outcomes. The second core theme was
entitled ‘the borderlands of patient-centred goal planning’, and related to the unknown and
unpredictable nature of conversations with patients and families when attempts were made to
engage with them over goal planning. The metaphor ‘borderlands’ was used to refer to this
second theme because of its association with movement away from the familiar and towards
new territory, with a lack of guides regarding progression through this new territory, and with
a sense of risk.
The substantive theory that was constructed from this study describes the consequences
arising from attempting to navigate through the borderlands of patient-centred goal planning
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in an environment where certain goals were already privileged. When there was alignment
between privileged goals and the objectives, attitudes and perceived capacity of patients and
family members then goal planning progressed relatively smoothly. However, when such
alignment was poor, interactional dilemmas emerged for clinicians when they attempted to
engage with patients and family members over goal planning. In such circumstances the
clinicians employed strategies to navigate their way through these interactional dilemmas,
while retaining control over the privileged goals.
The results below begin with a presentation of the characteristics of the various
participants involved in this study. This is followed by a description of the characteristics of
the approaches to goal planning employed by each of the rehabilitation services. The
substantive theory arising from this study, with reference to its two core themes, is then
presented and explored in depth, with specific examples from the data gathered. Finally, the
impact of privileged and patient-centred goals on the delivery and consumption of
rehabilitation services are explored and the financial and organisational influences on these
core themes are discussed.
6.3.1 Participant characteristics
A total of 46 people provided written consent to participate in this study. The study
population included nine patients, seven family members, 28 health professionals and two
physiotherapy students (who happened to be working on the ward during the time data were
being collected).
6.3.1.1 Characteristic of participating patients
The patient group included both men and women ranging in age from 57 to 92 years.
Most patients were of New Zealand European ethnicity, but the sample included one patient
of Asian ethnicity and one of Pacific Island ethnicity. Two of the patients had prior hospital
admissions for strokes in the past, and a further two had evidence of old cerebral infarcts on
brain scan imaging, but no history of hospital admission for such events.
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The patients differed quite substantially in terms of the severity of their disability on
initial presentation to the rehabilitation unit. The least impaired patients presented with only
minimal impairments of mobility, requiring just supervision for safety when walking around
the ward. These patients also tended to have no significant limitation in cognition or
communication, and if impairments were present, these were only mild in clinical terms (for
example, mild dysarthria or subtle problems with high-level executive functioning). In
comparison, the most impaired patients presented with an array of severe disabilities,
including serious problems with mobility (for example, requiring assistance from two or more
staff to sit upright without falling), with perception (such as marked visuospatial neglect), and
with language, swallowing, cognition, and continence of bowel and bladder. A few of these
more impaired patients also presented with serious co-morbidities, with one patient nearly
dying on the rehabilitation unit on two occasions due to a pulmonary embolus and kidney
failure.
In general, the patients with the most severe impairments tended to have the greatest
involvement of family members while on the ward. Of the nine patients, one was deemed
unable to provide written consent to participate in the study, and instead had this consent
provided for her by her next-of-kin (as per the study protocol). A further two patients, who
had partially impaired capacity to understand the study in full, provided signed written
consent, but did so with support of their family members. One of these two patients for
example, had English as a second language, and required a family member to translate the
study information before she could provide written consent. In all these circumstance the
supporting family members also provided written consent for their own participation in the
study.
The outcomes following inpatient rehabilitation also ranged widely for the participants.
Six of the nine participants succeeded in returning home to the community following
discharge, with two of the younger patients managing to return to part-time paid employment
within four month following discharge. The remaining three patients however did not return
to their previous homes, and were instead discharged to residential facilities; two requiring
hospital-level care following discharge. Demographic information about the nine patients has
been summarised in Table 9. Group data rather than individual data have been presented in
this table in order to preserve the patients’ anonymity.
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TABLE 9: Characteristics of participating patients in the study

Gender 5 women, 4 men
Ethnicity 7 New Zealand Europeans, 1 Asian, 1 Tokelauan
Age Range: 57 – 92 years; Mean: 77 years; SD: 11.8 years
Delay between admission Range: 4 – 21 days; Mean: 9 days; SD: 5.4 days
to hospital and admission
to rehabilitation
Length of stay in Range: 10 – 78 days; Mean: 37 days; SD: 25.3 days

rehabilitation
Total length of hospital Range: 18 – 90 days; Mean: 46 days; SD: 27.9 days
stay
Diagnosis 7 ischemic CVA, 2 haemorrhagic CVA;
3 left-sided CVA, 3 right-sided CVA, 3 bilateral CVA
Prior history of CVA Four participants had previous history of CVA (two of whom
had previous hospital admission for CVA); five had no
previous history of CVA
Cognition, Six participants provided informed consent for their

communication, and involvement in the study (having no or only mild cognitive
capacity to provide and/or communicative impairments); two participants provided
informed consent written consent with support from their next-of-kin (having
moderate cognitive impairments and, in one case, having
English as a second language); and one participant (with very
severe expressive and receptive dysphasia) had a family
member provide informed consent on their behalf
Mobility impairments on One participant was independently mobile; three were walking
admission with supervision but impaired balance; two were walking with
the assistance of a frame plus support of one to two staff
members; one was unable to walk but able to transfer from a
bed to chair with assistance; two participants were unable to sit
on the edge of a bed unsupported and needed physical
assistance with bed mobility
Family involvement in Four participants had family members who were actively
rehabilitation decision involved in their rehabilitation; five participants had family
making members who visited but were not actively involved in
rehabilitation
Discharge destination Six returned home; three (who previously had lived in their
own home) were discharged to a hospital-level care rest home
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6.3.1.2 Characteristic of the participating family members
Four patients had family members who also agreed to participate in the study. Each of
these four patients had one key family member (whom they had lived with prior to their
stroke) provide signed informed consent to participate in the study. In all instances these
family members participated in interviews during the study. These key family members
included two wives and one adult son and one adult daughter. One patient also had an
additional three adult offspring participate in the study by way of their involvement in a
family meeting.
6.3.1.3 Characteristics of the participating clinicians
The 28 health professionals who consented to participate in this study came from a
range of backgrounds, representing the breadth of knowledge and perspectives usually found
in an IDT. This group included: four physicians, two medical registrars, 11 registered nurses,
four physiotherapists, three occupational therapists, two social workers, one speech language
therapist, and one cultural advisor.
6.3.2 Characteristics of the formal goal planning processes
6.3.2.1 Establishing patient and family goals
Both units had a shared IDT rehabilitation plan for each patient on which the
rehabilitation goals were documented. This plan was stored near the front of the patient’s
clinical file. Both units also had established processes for gathering and documenting
information about the views held by the patients and/or their family regarding what they
hoped to achieve during the hospital admission. In both organisations these goals were
described as ‘patient and family goals’. In one organisation, this process involved an
admitting nurse collecting information from the patient or their family members, or both,
using a structured questionnaire to guide the discussion. Any elicited goals were then
documented on this questionnaire, before being transferred to the patient’s IDT plan. In the
second organisation, a nominated ‘key worker’ had the responsibility to gather information
about the patient and family goals, and to document these goals in the shared IDT plan.
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Again, a structured ‘Patient and Family Questionnaire’ was available for use by the key
worker to gather this information.
The collection of information about patient and family goals did not always follow these
organisational protocols however. Three factors appeared to limit this part of the formal goal
planning. Firstly, the documentation of patient and family goals in the IDT plan did not occur
in instances where the patient’s length of stay in the inpatient rehabilitation unit was short.
Thus, the three participants with the shortest length of stay (less than three weeks) had no
‘patient and family goals’ documented on the IDT plan. In all these cases however, evidence
existed in at least one other place in the patient’s clinical file (for example, in the progress
notes or in an allied health professional’s assessment form) that the patient had been consulted
at some point by a member of the IDT regarding their perspectives on the goals of
rehabilitation. The difference here is that this information was not documented in the part of
the clinical notes where other IDT members would expect to find it – in the IDT plan. From
these additional notes, it appeared that those with an impending discharge date tended not to
have goals that could be addressed in the hospital environment, within the time available, and
thus were perhaps considered less relevant to document in the IDT plan. For example, an
entry in the middle of the main body of progress notes for one patient read:
[The patient] Reports has [a] goal of returning to work in 10 days time… Appears
high functioning gentleman. Nil concerns re: home environment as mobilising (I)ly
on ward Ø aids… Discussed impact of fatigue + strategies for managing same.
Aware effects of fatigue could be exacerbated for a while upon returning home and
to work. Discussed return to work. Plans to test self out at home with building
tasks, able to have apprentice to supervise him around machinery use initially.
Aware of need for graded return to work initially… High functioning gentleman.
(I) with all cares on ward. Nil concerns identified with cognitive/perceptual ax.
H/V not identified ∴ able to dx home when ready from ward’s perspective.*
(Second occupational therapy entry in Bruce’s ‘Progress Notes’)
However, in this case ‘return to work’ was not listed in the section on the IDT plan for patient
and family goals.
*
(I) = independent; Ø = no; ∴ = therefore; ax = assessment; H/V = home visit; dx = discharge
161
A second factor that appeared to alter the process for formal collection of patient and
family goals was the staffs’ workload (or rather, arguably, the prioritisation of other clinical
activities over spending time to formally interview patients and family members about their
goals). In one case, this was illustrated by a nurse who gave a patient’s wife the ‘Patient and
Family Questionnaire’ to complete with her husband independently (instead of the nurse
assisting the family to complete this documentation). The justification given in this instance
was that the information had been requested for the team meeting that afternoon, but that the
nurse responsible for completing the questionnaire felt too busy with other clinical activities
to spend time guiding the patient and his wife in this task. The information about patient and
family goals was duly documented on the IDT plan, but the collection of this information did
not follow that ward’s stated protocol.
The third factor that limited the documentation of patient and family goals in the IDT
plan only related to one particular case. In this case the patient was severely dysphasic (to the
extent that she was not even able to accurately express ‘yes’ or ‘no’ in any way), yet the
clinicians did not feel confident that the family were able to represent her perspectives on
issues like goals. This situation was described by the social worker involved as being
‘particularly unusual’. Thus, the lack of patient and family goals in the IDT plan here
occurred because there were, ostensibly, no goals to document:
Researcher: What purpose do you think goal planning serves for this particular
case?
Social Worker: It kind of falls away to be honest. The person's care and welfare
and - takes over… But there are team goals probably… [but] these guys
[the patient’s adult children] have come already with their bags packed
saying we're going [to take her] into residential care so it's been done
and dusted before she even got here really. So if that was the case, then
in terms of goals, there are no goals. It's done, yeah.
(Interview with the social worker for Joyce)
An interview with the patient’s next-of-kin confirmed that this family member was in
fact opposed to his mother making functional gains, and actively disinterested in participating
in the rehabilitation process. This finding is a reminder that family members do not always
have a loving or even compassionate relationship with the patients who are in rehabilitation
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services. It is also a reminder that family members do not necessarily hold the same values as
the clinicians providing those services, regarding the purpose of rehabilitation.
Researcher: What do you think the aim of rehabilitation should be now with her?
Son: Oh God, I hope it doesn't rehabilitate quite frankly. I hope she never
gets her mind back to what she was, because she would be even more
angry. It's better - it would be better if she'd been left in the feathering
limbo world of you know, of calm serenity that she was in [the acute
medical ward]. But now as we're getting all this back. The old
personality's emerging and it will just be shit for everyone I tell you, and
she'll end up in the fucking dementia ward… I just wish that it [the
stroke] had been had been stronger and she'd gone. 'Cos I don't like her,
William. I'm her son and I don't like her.
(Interview with Joyce’s son)
6.3.2.2 Establishing IDT goals
In addition to patient and family goals, both units also documented shared team goals in
the IDT rehabilitation plan. (From hereon in, these team goals documented on the IDT
rehabilitation plan will be referred to as ‘IDT goals’ for the sake of clarity.) Although both
types of goals were documented on the same piece of paper, neither unit had a clear policy on
the relationship between the ‘patient and family goals’ and the ‘IDT goals’. It seemed
generally assumed however, that the ‘patient and family goals’ provided a focus for the ‘IDT
goals’, and this was reflected in the clinicians’ discourse around the purpose of goal planning:
Okay, so with the key working role generally we try and sit down with the patient
and come up with some things that they want to achieve and usually we try and say
well okay, if you want to achieve walking well there's things that you need to do,
so we break it down and we help them, you know, make small, achievable, short
term, whatever you like to call them, goals, but we sit with them in therapy and get
them to their long term goal, or whatever it is they want to achieve.
(Interview with the physiotherapist for Helen)
There were a number of marked difference between the characteristics of the ‘patient
and family goals’ and those of the ‘IDT goals’. Patient and family goals tended to be
recorded as a string of short phrases or single words, often referring just to areas of
impairment or a broad outcome of interest. For example, for one patient, the entirety of the
patient and family goals documented on the IDT plan consisted of:
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Return home, improve balance, get back to doing things (I)ly.
(‘Patient and family goals’ documented in Grant’s IDT plan)
In contrast to this, the documented IDT goals were more detailed, more specific (with a
generally narrower focus of interest), and were associated with specific timeframes for re-
evaluation. Thus the IDT goals reflected what is commonly understood by the ‘SMART’
acronym for goal planning. An example of one IDT goal was:
To be able to sit (I) on bedside, feet on floor, hands on lap 1 min. Timeframe: 1/52*
(An ‘IDT goal’ in Mary’s IDT plan)
There were also far more documented IDT goals than documented patient and family
goals. In total, 45 IDT goals were documented in the IDT plans, ranging from just one goal to
a maximum of 14 goals per individual case. IDT goals were also reviewed and updated
regularly, whereas patient and family goals were collected and documented on just one
occasion, near the patient’s admission to the rehabilitation unit. It appeared that IDT goals
could be written or altered by any of the clinical team members at any time. Frequently
however, this occurred during or after the IDT meetings, when each of the patients’ IDT plans
were discussed.
6.3.3 The privileging of certain goals
The first core theme constructed from this study’s data related to the privileging of
certain types of goals over others within the inpatient environment. The term ‘privileging’
here is used to describe a conferring of special advantage to certain goals, elevating them in
importance over others in clinical documentation and in discussion by the team. This first
core theme arose from examination of the process of goal planning and the characteristics of
documented goals. To reiterate, privileged goals in this context tended to display three key
traits: 1) an orientation towards physical functioning, 2) short timeframes for their
achievement, and 3) conservative estimations of progress.
*
1/52 = 1 week
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6.3.3.1 Orientation towards physical functioning
Of the total 45 IDT goals recorded in this study, 38 related to physical function
(mobility, self-cares, hand or arm function, bowel or bladder continence, and basic
communication). Of the remaining seven ‘goals’, two related to making decisions about
where to live following discharge (a pragmatic task required to discharge some patients from
hospital at all), three described tasks for the clinicians to complete rather than outcomes for
the patient to achieve, while the remaining two were not specific enough to clearly identify
what they were about at all (e.g. ‘Trial aids to assist reaching independence’ in the case of
Peter).
This is not to say that the clinicians ignored other aspects of health status or quality of
life in their interactions with patients; just that when discussion of these issues occurred, they
did so without reference to goal planning. For example, from the IDT meetings transcripts, it
was possible to identify times when team members shared and debated information relating to
the physiological, psychological, and social functioning of particular patients. Such topics
included issues to do with patient mood and depression, bowel function (diarrhoea and
constipation), kidney function, blood pressure, diet and weight loss, pain, family function,
epilepsy, and cognitive-perception impairments. However, in all these instances, no
consideration was given to the possibility that goals might be set around these issues. If it
was intended that clinical work relating to these other aspects of functioning contribute to the
achievement of some primary goal related to physical function (for example, to walk again),
these links were seldom made explicitly by the team in their documentation or in their clinical
discussions.
At an individual level, clinicians did demonstrate concern for patients that extended
beyond physical functioning (to include, for instance, psychological well being).
Occasionally, in the context of interviews, some clinicians even suggested that these
additional concerns were also ‘goals’ of rehabilitation. But again, these concerns were never
selected to become documented goals in the patient notes, and thus were never discussed as
such by the team or in interactions with patients or family members:
Speech Language Therapist: Well, you know, my goals on paper at the moment
are to achieve consistent yes/no and I think to do a little bit of education
now… But in the last couple of days I've seen somebody who appears to
165
be quite worried for some reason [that] her communication is affecting,

so my goal is that I can help alleviate that in some way, either by
providing her support – but has nothing to do with what she's worried
about or trying to come to the bottom of what it is she's worried about.
So yeah, there are all these other little things that I haven't
documented…
Researcher: So why don't you think all these things get document?
Speech Language Therapist: I think sometimes we don't think of them as goals, we

think of them as just part of what we do.
(Interview with the speech language therapy for Joyce)
In comparison to what clinicians said they regarded as goals, the actual goals they set as
a team, and discussed with patients, clearly emphasised this focus on physical functioning.
When case discussions during team meetings, for example, moved specifically onto the topic
of goal planning, these conversations invariably reverted back to issues of physical function:
Clinical Nurse Leader: We haven't really made any goals yet for him ‘cause
they’re just assessing him now, [the physiotherapist] is just walking him
now ‘cause they were walking him in medical… so there's no input yet,
and no goals – and OT, to be assessed – we could make – his wife
apparently – ‘cause he's on thickened –
Registered Nurse: Thickened fluids, yeah
Clinical Nurse Leader: So we could have a goal that he could start you know – a
goal towards feeding himself.
(First IDT meeting to discuss Peter’s case)
Incidentally, there was no apparent relationship between the setting of a goal and the
investment of time for discussions of particular issues in IDT meetings. In fact, some issues
around which no goals were set were discussed in depth, and over several subsequent
meetings. In other words, the apparent clinical importance of an issue did not appear to be a
factor for determining whether it would feature as an IDT goal. A more likely explanation for
this privileging of physical functioning was that IDT goals strongly supported a concept of
getting people back into their own homes, and on keeping them physically safe:
Researcher: Have you had any discussions with her [the patient] about goals?
Occupational Therapist: Yeah, yeah, I've spoken to her – um, on this form at the
end of it, I've just gone through with, I've just gone through short term
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and long term goals, and in order to go home she needs to be able to get
in and out of the bath safely to be able to access the shower and prepare
food and meals safely – she's actually looking at Meals on Wheels.
(Interview with the occupational therapist for Ruby)
This emphasis on physical functioning dominated all aspects of the data related to goal
planning in the rehabilitation wards. When inviting patients or family members to provide
their perspectives on what the goals of rehabilitation should be, clinicians very frequently
prefaced such discussions with statements that indirectly (but effectively) delimited the
potential scope of goals to just that of physical function. Sometimes this involved clinicians
starting such discussions with statements regarding their professional role, emphasising
aspects of that role which related to the rehabilitation of physical function. Other times,
discussion of a patient’s goals were preceded by questions regarding what physical function
the patient had been capable of prior to their stroke, leading the conversation toward future
goals on similar topics. Occasionally, clinicians gave examples of possible goals, presumably
as a way to introducing the concept of goals and goal planning to patient or family members,
but again, in the process, selecting examples that focused primarily on physical function.
Thus the manner in which patients and families were invited to engage in goal planning
influenced the types of goals that were reported and which eventually ended up on the IDT
plan:
Occupational Therapist: So the sorts of things that I look at are the really – the day
to day activities that people do. So that might be having a shower,
getting dressed, making a meal, getting around your house. A big
component of my job is making sure people are safe in their home
environments. So today I wanted to firstly explain my role, which I've
sort of done there, and ask you some questions about how you were
managing before having this stroke, what sorts of things you were
managing on your own and what you maybe needed help with and look
how you're going now and where the differences are… And also to set
goals with you too. So that's what I'd like to do firstly, if we can look at
that. I know it's a bit of a - bit of an airy fairy subject for some people,
but it is important to know what you want to work on, what you feel you
need to achieve. So if you think about how you're going now, how
you're managing on the ward at the moment, with all of your things like
walking, your personal cares, what do you think you need to improve on
or be doing better?
Patient: I don't know um – balance?
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Occupational Therapist: Balance, yup.
Patient: For a start.
Occupational Therapist: Balance yup. Is there anything else the nurses are helping
with that you think gosh, you know I really want to be doing that on my
own?
(Initial meeting between George and his occupational therapist)
Perhaps as a consequence of this emphasis on physical function, there appeared to be a

suggestion that the goal planning process should be primarily led by physiotherapists,
occupational therapists, and (less often) speech language therapists. Most IDT goals were
suggested and documented by people from these three professional groups. While involved in
discussions about goal planning, doctors seldom actually set IDT goals themselves. In the
IDT meetings observed, there were instances where doctors described their work with specific
reference to goals, only to have these ‘goals’ roundly ignored by the team, and not
incorporated in any fashion into the IDT plan. It may be that other health professionals did
not consider the medical concerns of doctors relevant to ‘goals’ of the IDT. However, the
point here is that there was no engagement between doctors and other IDT members around
this issue:
Physician: So okay, so and as far as medical goals, we, they don't, they want us to
do another MRI in sort of eight weeks or something. Six to eight weeks,
so we'll see.
Registrar: And – reducing steroids as well, so we'll see what happens with that
Physician: Yeah, so I think we'll aim to reduce the steroids by 2mg every week
okay.
Occupational Therapist: This goal you've put here about reaching down and
putting shoes on and sitting and losing balance, it's an achieved goal as
well, isn't it… [The IDT meeting continues without further reference to
medical ‘goals’.]
(Fifth IDT meeting to discuss Mary’s case)
Likewise, social workers, dieticians, and other clinicians seldom set goals. Goals were
occasionally set regarding nursing-specific areas of physical functioning (in particular, urinary
or bowel continence), but these were equally likely to have been suggested by the allied
health members of the IDT. Indeed, when talking about their role with respect to goal
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planning, nurses frequently referred to the implementation of goals that had been set by
physiotherapists or occupational therapists, rather than their own involvement in the selection
of goals for the team to work on:
Researcher: Do you think there will be goals that will relate to nursing
involvement with um, [Mary] in the future?
Nurse: Yes, I do, I think we will probably be following, well obviously her
medical condition that she's stable and that um, we'll be carrying out
probably when physio's say, okay, she's got to get up for afternoon tea,
you'll be doing all those things, her getting up in the morning, um –
[small pause] now I'm stuck –
(Interview with the primary nurse for Helen)
6.3.3.2 Short timeframes for goal achievement
Many health professionals in this study expressed a belief in the need to set both long
term and short term goals in rehabilitation. However, while long term goals featured in some
discussions with and between clinicians, it was the short term goals that dominated the
rehabilitation process. Of the 45 IDT goals, 35 were set with the documented intention for
them to be achieved within one or two weeks. Seven additional goals were set with no stated
timeframe for completion. The remaining three goals were set with the slightly longer
timeframe of either three or four weeks for completion. In other words, the clinicians
generally planned rehabilitation in one or two week intervals, concentrating the discussion of
goals on what could be achieved within the duration of an inpatient stay. In comparison,
other than occasionally using the expression ‘long term goal’ synonymously with the term
‘patient and family goal’, clinicians did not have a formal process for identifying or
documenting ‘long term goals’ as a team.
Even when investigating the colloquial use of the expression ‘long term goal’, it
appeared that, for clinicians, the concept of a ‘long term goal’ did not tend to extend to
projections of outcomes that were terribly far into the future. This was certainly the case
when compared with the perspectives of patient and family members regarding future aims or
objectives. More precisely, from the clinicians’ perspective, a ‘long term goal’ could include
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anything that might happen immediately following discharge; even simply the process of
‘going home’:
Yeah, because I mean, if he's only going to be here for a week, there are a lot of
goals that you're not going to achieve in a week. Um, yeah, so I'll probably write
down the goals I think he could achieve in a week but then write down that his
greater goals are a kind of long term goals that are still achievable and worth
working on so I'll probably pass him on to [the community physiotherapist]
(Interview with the physiotherapist for John)
In comparison, patients and family members viewed the goals of rehabilitation over
much broader periods of time. Even in discussion of their immediate goals, patients and
family members frequently moved from talking about their current situation to speculating
about other issues well into the future. Such issues included growing older, prevention of
further medical incidents of a similar nature, and how to integrate their current situation into
their future life in the community. In other words, patients and family members held a much
longer view of recovery from stroke than even those goals considered by clinicians to be ‘long
term goals’:
Researcher: So what do you think, from your perspective, what are your objectives
at the moment?
Wife: Well, I'm having to adjust them constantly because it took me a while to
get used to the fact that I would not get back the man I knew… I thought
if he can still enjoy the things we all do – sunshine, enjoy talk and, ah,
group singing - that's why the place that we were most interested in was
a place called [name of rest home]… the focus is on joining in with
games and singing and doing hobbies and they have a workshop for
people who live out of the precinct… and I thought, well, that kind of
life, I could - because they've got villas as well - so I could rent or buy
one of the villas and be there and support him, but I wouldn't need to do
the things that I find quite hard in his day to day care
(Interview with the wife of Peter)
Like the emphasis on physical function, the dominance of short timeframes in IDT
goals reflected the clinicians’ overriding sense of responsibility to discharge patients from
hospital, preferably to safe, independent living. While the clinicians expressed some interest
in the broader hinterland of the patients’ life (and that of family members) this interest
generally did not extend to the development of targeted goals. Even when clinicians could
identify that other problems might arise for patients following their discharge from hospital,
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they did not feel an obligation to document these as goals or specific work to address them.
The clinicians’ perspective on goal planning was thus restricted to a very specific period of
time – the duration of inpatient admission:
Occupational Therapist: See, long term, there's going to be other issues.
Researcher: Like what?
Occupational Therapist: Things like, you know, can she engage in the things that
she likes to engage in, can she go out of the house, will she be able to
meet her friends – she, you know, is she going to want to do that sort of
thing?
Researcher: Mmm. Is there any obligation to address those issues while she's in an
inpatient setting here?
Occupational Therapist: Um, less likely to.
Researcher: And why do you think that's less of a focus?
Occupational Therapist: It, it shouldn't be, but it's more um, I just find it's more,
more of a focus to actually deal with the discharge so that the
equipment's out, be able to do sort of follow up treatments as opposed to
purely assessing everyone. It's, it's a time thing and a case load thing
pretty much.
Researcher: Yeah, and why are those other issues considered more of a priority?
Occupational Therapist: Which? The ones we're getting –
Researcher: The ones you're addressing as opposed to the ones you sort of think
might be issues
Occupational Therapist: Um, it's the things that she needs to do in order to return
home… rather than the things that she'd like to do in order to return
home
(Interview with the occupational therapist for Mary)
Clinicians and the IDT teams thus appeared to orient towards goals that reflected their own
involvement with the person who had the stroke, rather than towards goals that reflected the
patients’ or family members’ life priorities.
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6.3.3.3 Conservative estimations of progress
Closely associated with short timeframes was a tendency towards conservative

estimation of progress in the selection and documentation of IDT goals. Clinicians talked
about these two factors (short timeframes and conservative estimation of progress) as the
practice of breaking rehabilitation down into small, achievable ‘steps’. There were multiple
factors which appeared to underpin this discourse. Firstly, this approach was discussed with
reference to a problem solving approach to rehabilitation: developing a strategy for solving
complex problems by identifying and addressing the component parts. Clinicians, for
example, would talk about the ‘steps’ (i.e. abilities or strategies) that a patient might need to
reach before they could go home. Secondly, this approach had some foundation in a belief
that rehabilitation needed to occur in a particular order (e.g. that patients needed to be able sit
independently before they could stand, before they could begin to learn to walk again).
Thirdly, this stepwise approach reflected a desire to be able to predict outcomes with
reasonable accuracy: to be able to state in a public forum (such as an IDT meeting) what was
being worked on and when it was going be achieved, as the achievement of IDT goals was
seen as an important indicator of successful rehabilitation in the inpatient environment.
However, it emerged from interviews with clinicians that accurate prediction of outcomes for
individual patients was often viewed as extremely difficult. Therefore clinicians had a
tendency to err on the side of caution when setting goals, in order to ensure that stated goals
would be met. In other words, being realistic when goal planning was highly valued; being
ambitious was not.
The following extract from an IDT meeting provides a good example of the privileging
of goals that involved conservative estimation of progress. This case centres on Mary, a
woman who had been admitted to hospital following a very severe stroke. On initial
assessment in the rehabilitation ward, Mary had been unable to sit independently on the edge
of her bed, appeared to have some cognitive problems and was incontinent of bowel and
bladder. Her prognosis had been poor. However, after four weeks Mary had begun to make
improvements in her function at a rate which had surprised and excited the clinicians. In this
meeting, the physician raised the possibility of ‘walking’ being documented as an IDT goal.
Mary’s physiotherapist however, while agreeing that ‘walking’ was a possibility in the future
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for Mary, successfully argued against considering it as a goal until some easier ‘steps’ had
been reached first:
Physician: So we should have a goal about walking, should we?
Physiotherapist: Well, I want her to be able to stand first because the problem is as
soon as you take her out of the parallel bars, she falls over, so as long as
she's got both hands on the parallel bars and she can pull herself forward
like this the whole time, she can walk
Physician: But there's no – I can't see any real reason why she shouldn't be able to
um, to walk eventually
Physiotherapist: Oh, yeah, eventually. But I kind of, I don't know how long a
timeframe to put on that, so I've just set her the one to stand this week
and then if she can achieve that we should be able to look at walking
next week.
Physician: Okay, alright then
(Fifth IDT meeting to discuss Mary)
In fact, there were many examples in this study of situations where, when faced with
two possibilities for goals, clinicians tended to select the easier (i.e. more ‘achievable’) one.
One consequence of this was that, at times, it appeared some IDT goals reflected more what a
patient was currently capable of (and what clinical work was currently being undertaken), not
what level of functioning they might possibly achieve in the future. In other words, solutions
to clinical problems and plans for interventions tended to be decided on first, before a goal
would be set. Thus, in this study, IDT goals appeared to describe, rather than drive, the
rehabilitation process:
I don't think with her it's realistic to say [in a goal] oh… she'd be washing and
dressing independently ‘cause it's such a big thing for her and you know, it's a big
thing for her to sit out for half an hour, so I don't really think it's as appropriate to
focus on such a big area of washing and dressing. I mean, a lot of people, yeah, I'd
put [in an IDT goal] to be independently washing and dressing but if I'm trying to
look at her as an individual, then, what she needs is not to be engaged for an hour
in something that just absolutely shatters her after twenty minutes.
(Interview with the occupational therapist for Mary)
In summary then, the rehabilitation teams had processes for collecting information
about the perspectives of patients and their families, and they expressed some interest in the
wider context of patients’ lives, but, when engaged in the process of goal planning, they
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privileged certain goals over others. These goals placed heavy emphasis on physical function,
on short time frames (within the duration of inpatient stay), and on conservative estimation of
outcome. They were driven by belief systems regarding recovery needing to follow a
stepwise path, and an onus on physical safety and the physical components of discharging
patients home. However, as will be discussed next, clinicians also held strong beliefs in the
need for goal planning to be ‘patient-centred’. To engage in a patient-centred approach, goal
planning required health professions to enter the unknown: the borderlands of patient-centred
goal planning.
6.3.4 The borderlands of ‘patient-centred’ goal planning
The second core theme arising from this study related to the unknown and unpredictable
nature of conversations with patients and families when the clinicians attempted to engage
with them over goal planning. Privileged goals (as described above) represented, for
clinicians, known territory. These goals related to activities that the clinicians were
comfortable performing, felt was within their professional role, and which addressed what
they believed were their main work responsibilities. However, the concept of ‘privileging’
certain goals seemed at odds with other values held by health professionals in this study; in
particular, with the tenets of ‘patient-centred’ rehabilitation.
To understand this tension, it is firstly important to understand how strongly the

clinicians in this study expressed beliefs regarding a ‘patient-centred’ approach. When asked
about the purpose of goal planning with respect to the specific cases under investigation, or
when introducing the concept of goal planning to patients or their family members, clinicians
frequently referred to a need to make the process of rehabilitation relevant to the lives of the
people receiving the services. For the clinicians, this involved finding out what was important
to patients and encouraging them to have a voice in determining what should be the focus of
interventions. In other words, one of the dominant reasons expressed by clinicians for
undertaking goal planning at all was to make the process of rehabilitation ‘patient-centred’.
This was an ideal that was consistently expressed across all professional disciplines and
across all cases:
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So I guess with someone like [Ruby], everyone, like – she wants to achieve this,
she has some time [on the ward] and we work really hard at trying to achieve that,
and then she goes home or then she goes back to wherever she's come from, so… I
guess because of the goal planning, it becomes a lot easier and a lot more patient-
centred and directed, yeah.
(Interview with the physiotherapist for Ruby)
Even in situations where a patient’s ability to contribute to goal planning was

compromised, the clinicians still expressed a strong desire to maximise opportunities to
involve them. For example, one patient, Joyce, was so severely communicatively impaired
that she was entirely unable to understand questions about goal planning, let alone express her
own perspectives on them. In this case, Joyce’s speech language therapist stated that the
initial goal of therapy was to get her to the point where she was able participate in such
matters (although, the documented IDT goal was not specifically worded along these lines):
For somebody in that kind of state of severity, I don't talk to them much
necessarily about goals although I try and get a holistic view of where they're at.
But in terms of formal goal setting, my goals are to get her to the point where she
can write her own goals, essentially.
(Interview with the speech language therapist for Joyce)
The challenge of patient-centred goal planning however was that when patients (or their
family members) were asked to state what they wanted to achieve in rehabilitation, their
answers were at times unexpected or not aligned with the type of goals that the clinicians
themselves believed should be the focus of rehabilitation (i.e. the privileged goals). In this
context, conversations with patients and family member had the potential to become
unpredictable. The interests and objectives of patients and family members did not
necessarily match what clinicians themselves believed should be the scope of inpatient
rehabilitation. Inviting patients and family member to present their perspective on the
objectives of rehabilitation also carried with it a risk that patients or family members might
raise topics for discussion that were awkward or time consuming for the clinicians to address.
Examples of such difficulties included goals with timeframes that extended way past the
expected duration of the inpatient stay, issues that centred on psychological or emotional
sequelae of stroke, issues that did not appear to directly relate to the disabilities arising from
the stroke (e.g. previous family dysfunction), or goals that the clinicians believed were
unrealistic or irrelevant to clinical rehabilitation.
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Because we're - most of the time we're uncomfortable with that sort of rather vague
timeframe and have trouble defining what it is that's - 'cos they [patient and family
goals] are not achievable within a hospital stay almost by definition. And it
requires enormous emphasis on psychological health, and we're very
uncomfortable about that too.
(Interview with Helen’s physician)
This type of situation raised numerous interactional dilemmas for the clinicians in this
study. A common dilemma in this context was how to respond to the patient’s or family
member’s discussion of goals, while retaining control over the direction of this interaction,
and over the types of goals set. In other words, once clinicians entered into a discussion with
patients or family members about their perspectives on goal planning, they had to somehow
then navigate their way through these interactions when they inevitably deviated ‘off the
beaten path’, away from privileged goals.
The clinicians in this study demonstrated a number of discursive strategies for

navigating their way around interactional dilemmas resulting from the involvement of patients
and family members in goal planning. Some of these strategies involved pre-empting such
dilemmas by directing discussions of goal planning towards privileged goals from the outset.
These strategies have already been discussed in the section above on privileging physical
functioning in goal planning (c.f. Section 6.3.3.1).
Another strategy however was to simply ignore stated goals that were deemed outside
the scope of the inpatient rehabilitation interventions. The following extract is an excellent
example of this type response. Here, Ruby, a 90 year old woman with a mild stroke, was
being interviewed by her primary nurse as part of the unit’s usual approach to IDT
assessment. For this assessment, Ruby’s nurse was completing the structured questionnaire
used by the team to identify ‘patient and family goals’. When given the opportunity to
suggest a goal, Ruby raised an unexpected topic. The nurse, in response, contributed some
brief conversational pleasantries, but then referred quickly back the form in her hand,
returning the discussion once again to topics related to privileged goals:
Ruby: And then another, what I'm going to do is - I can, I can call this a goal -
it'd be accurate - but what I thought I'd like to be in a position to do was
get on the Internet
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Nurse: Mmmm. Ohhh, interesting, you've got a computer at home?
Ruby: No, I haven't. That's the point
Nurse: Oh, okay
Ruby: They're expensive
Nurse: Yeah, they are expensive
Ruby: Yeah, so
Nurse: Now the other thing I need to just check with you is – [The nurse moves
onto the next topic on her checklist. No more discussion about the
Internet is held.]
(Initial nursing assessment for Ruby)
Putting this interaction in context, some additional information about Ruby is required.
Ruby was a very politically active woman, who had a life-long interest in issues to do with
human rights at an international level. Her stroke had restricted her mobility, making it more
difficult for her to access the political groups in the community that she was an active part of.
The Internet, for Ruby, represented a possible solution to her problem of maintaining links
with her community and to the wider world, while coping with the challenges of an aging
body. For the rehabilitation team, however, assisting Ruby to gain access the Internet was not
considered within the scope of their work. Their approach instead (as always) was to set an
‘achievable’, short-term goal around physical function: to improve Ruby’s outdoor mobility,
with the intent that this would hopefully allow her to catch the bus in order to physically
return to her community groups. One of Ruby’s IDT goals thus became: "To mobilise safely
and independently [with a] stick for 7-8 minutes”, with the documented timeframe of two
weeks set to achieve this. Ruby’s suggestion might have been a better long-term solution
(addressing the same problem of community participation), but this was not even raised for
discussion by the team.
To be clear, as in other instances of this type of interactional dilemma, the nurse

conducting the interview with Ruby was not unfamiliar with the concept of patient
involvement in goal planning. In fact, right at the beginning of this interaction, this nurse
explicitly stated her intention was to document exactly what Ruby said about her current
situation and her goals: (‘…so what I'm going to do is to write down exactly what you've said,
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okay, cause it's what you're saying about your rehabilitation’). Nonetheless, even with these
stated intentions, clinicians are still drawn away from genuine exploration of patient
perspectives by a drive to produce IDT goals that fit some preconceived notion of what
rehabilitation goals should be about.
In this above interaction, is it entirely possible that the objective of accessing the
Internet was so far outside this nurse’s understanding of what rehabilitation involved that she
failed to even identify it as a subject relevant to the discussion of goals. Perhaps this is why
the nurse did not ‘write down exactly’ what Ruby said on the matter. This explanation
however was not defendable for most other interactional dilemmas relating to patient-centred
goal planning such as, for example, the case presented below.
The following case provides an example of a situation where a more extended

interactional dilemma arose, requiring more complex strategies to navigate around discussion
of non-privileged ‘patient and family goals’. In this episode, Paul’s wife was being
interviewed by his occupational therapist in order to make decisions about what should be the
goals of therapy. (Paul himself attended this meeting, but was extremely fatigued and slept
through the majority of it.) Once again, at the beginning of this interview, the occupational
therapist in question expressed an explicit intention to identify and set goals around what Paul
himself wanted to achieve in rehabilitation. Paul’s wife thus stated that their goals were to
improve Paul’s vision (to allow Paul to read the newspaper and complete crosswords), to
address his faecal incontinence, to improve his swallowing, and to improve his ability to
interact with other people. The occupational therapist in this case however, believed it was
important to set and prioritise a goal around Paul improving his ability to shower himself (a
privileged goal). Because this had not come up as a patient and family goal, the occupational
therapist raised this as a possible goal herself. Paul’s wife however attempted to divert the
discussion of goals from showering by stating her own opinion that Paul’s ability to shower
was not in fact impaired by his stroke, merely limited by fatigue:
Occupational Therapist: Alright - so, um, it's just round swallowing and
incontinence and the eyes and he's mentioned the communication - um,
so basically what I'll probably be doing with him is looking at bit of -
probably start with a bit of showering. I know that he's getting full
assistance at the moment, um, but maybe getting him doing, you know
like, I can take him for a shower sometimes instead of the nurse, and get
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him doing some things for himself and form some goals around what he
can do at the moment, um -
Wife: Yes, well the nurse, [nurse's name], she's very good, she said - you do it
Occupational Therapist: Oh, that's good
Wife: And put the shower all over him - she handed him the cloth with the
soap - washing himself
Occupational Therapist: So with the prompting he's quite –
Wife: Oh, yes
Occupational Therapist: Yeah, that's great - so maybe getting him doing his top
half independently
Wife: Cause I think personally it's not lack of being able to, it's just the fact
that half the time he's absolutely stuffed and all he wants to do is sleep
(Initial interview of Paul’s wife by Paul’s occupational therapist)
In response to this, the occupational therapist in this interaction moved momentarily on

to other issues for discussion. However, she soon returned to the topic of showering, asking
again whether showering was something that Paul would like to work on. Rehabilitating
Paul’s ability to participate in his self-cares was clearly considered a priority by this clinician.
The dilemma for this occupational therapist only compounded however when Paul’s wife
stated even more explicitly that a goal around showering would not in fact be a meaningful to
him:
Occupational Therapist: Yep, alright - okay-doke - um, and do you think, you
know, some of the things that are important to him - do you think
showering is something that he'd like to do? Or do you think he'd be
quite happy to get assistance with that? Do you know what I mean - like
do you think for him, showering would be something that he -
Wife: Not important at all, no
Occupational Therapist: No
Wife: He actually prefers a bath…
Occupational Therapist: So for him, it’s probably more about the communication,
and bit or pieces -
Wife: Definitely –
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Occupational Therapist: Rather than about – well, he doesn't mind getting help
with a few other things
Wife: No
Near the end of this interaction, the occupational therapist introduced one final strategy
to progress her agenda to put showering on the IDT rehabilitation plan. This strategy
involved providing some commitment (albeit, a loose commitment) to address one of the four
patient-centred goals, followed by an authoritative statement to work on showering regardless.
At this point in the interaction, Paul’s wife relented:
Occupational Therapist: We can maybe - I can talk to the Blind Foundation, see
what they've got
Wife: That would be brilliant, thanks
Occupational Therapist: Probably would be - work very slowly with that one, but,
you know, not quite yet, but um, yeah - something like that would be
good if that, that was what he was really keen on…
[This is followed by a brief discussion of how fatigued Paul is, then -]
Occupational Therapist: I might book in to give him a shower and maybe possibly
next week - yeah, maybe early next week
Wife: Great
Occupational Therapist: And see how he's going with that
As a footnote to this example, by the end of Paul’s rehabilitation one goal had been set
around his self-care in the shower, one goal around his incontinence, but no goals were ever
set regarding Paul’s visual function, his communication, or his ability to read and write. On
the day before his discharge his wife stated that she herself had initiated contact with the
Blind Foundation without input from the IDT team. There were no notes in the clinical
record to the contrary.
Finally, some weeks after his admission, Paul himself became able to express his own
opinions more clearly regarding his goals. It turned out that Paul, who was Buddhist, was
more concerned about his capacity to do meritorious deeds and thus to achieve spiritual
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advancement. This goal, of course, did not fit the scope of privileged goals in the
rehabilitation context, therefore did not feature in any team discussions:
Researcher: So um, what do you want to achieve in the next couple of months?
Wife: What sorts of things would you like to make most progress in?
[A long pause before Paul replied]
Paul: Peace and tranquillity.
(Interview with Paul and his wife near discharge from hospital)
6.3.5 Alignment between patient-centred goals and privileged goals
The theory constructed from this study explains how interactions between
interdisciplinary teams, patients and family members are mediated in part by the degree of
alignment between the goals privileged by the IDT and the objectives, attitudes and perceived
capacity of patients and family members. In the examples above, interactional dilemmas
arose for clinicians when there was a lack of such alignment. Reciprocally, navigating the
borderlands of patient-centred goal planning was considerably easier when the objectives,
attitudes and perceived capacity of patients (or their family) fitted well with the goals that
were privileged by the rehabilitation system.
Firstly, the sorts of interactional dilemmas described above were less likely to occur
when the patient’s or family member’s goals focused explicitly on physical functioning and in
areas which the clinicians felt gains could be made during the period of hospital admission.
In fact, these goals quickly become adopted as IDT goals (after some minor alteration of
wording to fit the preferred IDT goal format). John, for instance, consistently and clearly
articulated two goals to all clinicians he came into contact with; often before he was even
asked for his perspective on the goals of rehabilitation. These two goals were: to return to
lawn bowling and to return to casual work as a skilled labourer:
Pretty straightforward really, he pretty much tells you what he wants before you
even get to asking him really, he knows exactly what he wants to achieve and what
he wants to go back to so… So, I think, I think goal setting with him is also very
useful because it does point you to the point that he is really high functioning and
that there are things that he wants to go back to and he's not satisfied to just be able
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to look after himself or potter around, he wants to go back and do things that are
really high level… he has goals that you can directly take and make into treatments
(Interview with physiotherapist for John)
One of John’s goals thus became: ‘To be able to ↑ hand grasp to use screwdriver + adjustable
wrench effectively’, with a one week timeframe for completion.
Interestingly however, there was one other goal that John expressed consistently and
clearly, to all clinicians he came into contact with, but which did not feature in quite the same
way in the documented IDT plan. This goal was to quit smoking. John, in fact, was very
concerned about achieving this goal and frequently referred it, both in his interviews for this
research and in his interactions with the clinicians on the ward. He was aware that smoking
was one of the major contributing factors to his stroke, and that if he was to prevent another
stroke with potentially worse consequences he was going to have to quit smoking. Only one
IDT goal however was documented that related to this objective, and technically, this ‘goal’
was in fact a task that was completed by the social worker in the IDT: ‘To provide written
information on “Quit Smoking” to support [John] in doing so.’ This ‘goal’ was written on the
day that the information was provided and given the somewhat redundant timeframe of one
day for completion. According to the theory that emerged from this study, John was not
assigned an IDT goal to ‘quit smoking’, because this was not a goal that was privileged by the
rehabilitation system. Firstly, John’s goal related to a behavioural change rather than physical
functioning, so was considered a lower priority with regard to the IDT plan, and secondly the
timeframe for re-evaluation of this goal would have extended past the date of discharge from
hospital, therefore was not considered relevant to the main work of the inpatient clinicians.
Interactional dilemmas related to patient involvement in goal planning were also less
likely to occur when patients entered into the rehabilitation environment with a specific set of
skills and attitudes that were valued by the clinicians. These preferred skills and attitudes
included a propensity for setting personal goals and an orientation toward physical
independence. Both of these were demonstrable in the case of John, above. (The reverse of
this would be a lack of previous experience or knowledge regarding goal planning or an
apparent disinterest in working toward independence.) Clinicians also found it easier to
engage in patient-centred goal planning when they believed the patients and family had
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‘realistic’ expectations regarding their outcomes and a willingness to compromise if the

clinicians disagreed with the how achievable the patient and family goals were:
Yeah, there's no conflict cause what she actually wants is do-able, it is realistic,
um, and she is happy to compromise, you know, it's realistic that she won't need
the frame but it might not be quite so realistic that she will manage without
anything, but she's quite willing to compromise on a walking stick and that is quite
okay with her.
(Interview with physiotherapist for Ruby)
For patient-centred goal planning to be completely non-problematic however, the

clinicians also had to believe that a patient had the capacity to achieve the goals they wanted
to set, regardless of how oriented they were to physical function or how much they expressed
the ‘right’ attitude. For instance, another patient, Helen, was equally as articulate as John
regarding her goals, equally determined, and equally oriented toward improving her physical
independence; in particular, to improve her ability to walk. However in this case, the IDT
members were not convinced that Helen would be able to achieve her objectives, and thus
Helen’s goal to walk again was never documented as an IDT goal. Instead a modified goal,
with a more conservative estimation of outcome (in other words, a privileged goal) was set:
‘To sit independently in normal chair safely’, with a timeframe to achieve this of one week.
This tension between patient-centred goals and privileged goals again resulted in interactional
dilemmas for the clinicians involved; in this case, how to make the IDT goals relevant to
Helen’s life:
I actually always want to set goals that are achievable, but I don't know what we
can achieve that she would want - that was meaningful to her.
(Interview with Helen’s physiotherapist)
This became an unresolved tension for the physiotherapist in her interactions with Helen,
making all further discussion of goals with her awkward and unsettling. The physiotherapist
therefore endeavoured to make the privileged IDT goal (to improving sitting balance) more
relevant to Helen, by linking it to other possible objectives, such to improve her ability to
participate in self cares. Another strategy attempted later was to confront Helen with the
possibility that she was unlikely to be able to walk again, while encouraging her to re-evaluate
her goals:
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Helen: They asked me my ambitions when I first started.
Researceher: Yup, and what did you say?
Helen: To be able to get out of bed and walk to my own toilet in the night. But
she [the clinician] said I have to have more realistic, so I've changed it
and I'm going to tell them what my new one is.
R: What's your new one?
Helen: My new one is to be able to be pushed in a wheelchair to my son's car

when he can take me for a drive to see the ocean. I would love that.
(Interview with Helen)
However, while this new goal (to visit the ocean in a wheelchair with her son) was discussed
informally by the team, it never featured as an IDT goal, and therefore was never specifically
worked on.
6.3.5 Impact of privileged goals and patient-centred goals on the provision of

rehabilitation
6.3.5.1 Influence on choice of intervention
As mentioned above, because privileged goals were associated with conservative

estimations of outcome and relatively short timeframes, they tended to describe the
rehabilitation process for individual patients rather than drive it. Decisions regarding
treatment opinions would be made first, then ‘realistic’ goals would be set to reflect these.
This approach meant that IDT goals could be made less ambitious to match not only the
perceived capacity of patient, but also the availability of resources (including human
resources). The clinicians in this study never appeared to use goals to influence their
individual and collective striving towards potentially better outcomes for patients.
At the moment, like I say, I'm focussing very much on personal cares. I'm not
really looking at the [bed to chair] transfers at this stage actively um, just purely
because, I suppose it's manpower. We need assistance of two to be able to do
anything like that.
(Interview with Mary’s occupational therapist)
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When ‘patient and family goals’ had the potential to alter the clinicians’ choice of
intervention, these goals no longer aligned with the sorts of goals that the health professionals
tended to privilege, and therefore were either altered or ignored. (One further approach to
‘ignoring’ such goals was to informally relegate them to the category of ‘long term goals’,
which were therefore outside the scope of inpatient IDT goals.) For Helen’s physician, this
reflected an approach to goal planning that was more about ‘mechanistic task allocation’:
I tolerate the term goal planning as a sort of mechanistic task allocation thing that
we do in hospital, but I think we probably spend way too much of our time doing
it, doing the process, documentation and stuff for any value that that might
achieve.
(Interview with Helen’s physician)
For this physician, if goal planning was to achieve any real benefit it needed to have a much
stronger focus on the patient’s own perception of their life in its broadest context (including
psychological and spiritual goals), and not just on the privileged goals observed in this study.
Even when patient and family goals aligned with privileged goals, these did not
necessarily alter the selection of interventions for therapy. For example, in the case of John,
goals around improving his upper limb function were set in order to progress towards his
clearly articulated (and documented) goal of returning to bowling. As the researcher
observing these interactions, I assumed that this would have resulted in the development of
exercises specific to bowling. However, on interviewing John following his discharge from
hospital, this did not evidently reflect his experience:
Researcher: In your therapy the physios were interested in your bowling, and they
sort of - ah I imagine they developed goals and exercises around your
bowling?
John: They certainly had an interest in the game of bowls and the fact that I
was you know a bowler and had bowling as a hobby. They were
unaware of what it consisted of… but they didn't set any special plan I
don't feel, to suit a bowling action… they studied me – they made me
bring my bowls to the hospital… But the exercises that I was performing
didn't change, they were the same exercises prior to them seeing me
bowl and they kept up the same exercises after. They didn't change
them at all.
(Interview with John three months following discharge from hospital)
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Nonetheless, John appreciated the discussion of his personal goals in hospital. He

expressed on several occasions how attentive the clinicians had been and how interested and
understanding they were of his perspective, despite the age difference between himself and
his therapists.
Broadly speaking then, goal planning appeared to change little about the provision of
rehabilitation in either of the services involved in this study. There were however two
exceptions to this finding (two ‘negative cases’ from a grounded theory perspective): one
specific and one general. The specific exception involved the case of Ruby, the 90 year old
woman with an interest in international politics. In this case, the identification of a goal to
return Ruby to her community groups resulted in a decision to extend her inpatient admission
by one week, with the explicit intention to use this extra time to work intensively on her
higher-level mobility. Ruby was ready for discharge from the perspective that she was
deemed safe to return home, but inpatient rehabilitation was considered her best opportunity
to maximise her mobility in community environments. Here, a ‘patient-centred’ approach
appeared to directly alter a decision regarding rehabilitation interventions. It is possible in
this case that this exception occurred because the goal to maximise Ruby’s physical mobility
fitted so neatly with the concept of privileged goals, but also because Ruby’s physiotherapist
was effective in arguing the case for extending Ruby’s period of inpatient stay. (Incidentally,
Ruby herself was more than happy to concur with this recommendation by the team, and
quickly aligned her personal goals with those of the team. This ability to adapt her
perspective to match those of the IDT was a characteristic of Ruby’s that was valued by the
team and which undoubtedly facilitated her involvement in the rehabilitation process.) There
were no other specific examples observed during this study where goal planning had such a
profound impact on clinical decision making.
The second (more general) exception to the finding that goal planning had little
influence over clinical decision making related to the planning of discharge destinations.
When a specific goal was set around a patient’s discharge destination, clinicians then used this
information to make decisions about the provision of specific environmental aids (such as
rails over baths and the prescription of mobility aids suited to the home setting) and about the
training of family members who were destined to become carers. This general exception
however is less compelling than the specific exception above. The characteristics of
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privileged goals that emerged from this study appeared to fit an agenda to prioritise the safe
discharge of patients to their home environments. It seemed unsurprising therefore that
details regarding discharge destination would alter the process of discharge planning to ensure
it was safe and sustainable.
6.3.5.2 Influence on hope

For many of the participants in this study goal planning was associated with the
concept of hope:
Their whole life has changed, you know, and it’s, you know, that their goals might
be adjusting to this new disability, um… but it’s something to aim towards and to
generate some hope.
(Interview with the social worker for Paul)
Having goals was considered to provide hope and having hope was considered fundamentally
important for recovering from a stroke:
Researcher: Why is hope so important do you think?
Helen: Well, silly question! How can you improve if you haven’t got hope?
(Interview with Helen three months following discharge from hospital)
Clinicians however expressed some unease when discussing the concept of hope with
respect to goal planning. This unease arose from the need to privilege ‘realistic’ goals, and an
associated belief in the risks of giving ‘false hope’ to patients and their family. Clinicians
were concerned about ‘false hope’ for two main reasons. Firstly, clinicians wished to protect
patients and family members from the psychological consequences of experiencing
disappointment if they did not achieve what they were hoping for. Therefore, they tended to
encourage patients and family members to lower their expectations when these were
considered out of line with what the health professionals predicted a patient’s outcome would
be. Secondly, clinicians also felt an onus to lower the expectations of patients or family
members when they were seen to be pursuing a course of action that the clinicians themselves
considered to be difficult. For example, Mary’s daughter stated consistently from the very
beginning of Mary’s admission to rehabilitation, that she would be taking her mother home, to
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be her carer, regardless of Mary’s level of recovery. The clinicians involved in this case
however believed Mary’s prognosis to be poor and so felt an obligation to ensure that Mary’s
daughter did not have false expectations regarding the future she was setting herself up for.
We should realistically aim to get good sitting as our primary focus… it’ll just be a
bonus if we can get her to stand to be able to go from a chair to her bed…
Walking, I realistically don’t think we’ll get, but we’re not going to rule it out.
(Physician at Mary’s family meeting)
Clinicians therefore frequently attempted to balance setting realistic (privileged) goals with
the desire to retain hope. This resulted in some personal conflict for individual clinicians
when there was a substantial divide between privileged goals and patient and family goals.
I think part of why I'm really struggling to say to her you're not getting better and
you need to think about this, is I don't want her to stop trying. I don't want to kill
all her motivation and hope… While I've still got her, I need her to keep working,
[but] I don't want to send her away completely disappointed that she never
achieved what she thought she was here to achieve.
(Interview with Helen’s physiotherapist)
Interestingly, however, the clinicians’ attempts to promote realistic goal planning and to
discourage the preservation of false hope did not appear to reduce the psychological stress of
patients or family members, or better prepare them for their future. In the case of Mary, the
IDT substantially underestimated her potential outcome. Not only did Mary leave the hospital
walking, but within three months her daughter reported that she had fully returned to her
previous level of independence. However, the daughter’s experience of being encouraged to
set ‘realistic’ goals was, in retrospect, a negative one. While delighted by Mary’s recovery,
her daughter believed the team’s active discouragement of her hope contributed to her
experiencing considerable distress while Mary was in hospital:
I hope that your thesis makes a difference in the way that professionals actually set
goals and that they don't – it's not false. It's not wrong to give out hope and it's not
- it's like the walking… I think it's one thing to be realistic but another thing to um
prevent giving hope, because nobody said the – the surprising thing out of it all
nobody said that she was going to be normal and that's what she is, and nobody
said - 'cos I was just expecting the worst scenario that she was going to be in that
condition for good. Nobody said that she was going to improve.
(Interview with Mary’s daughter three months after discharge from hospital)
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Not all patients of course achieved the level of improvement that Mary did. Helen, for
example, made negligible recovery during her inpatient stay, and so was discharged to a
hospital-level care rest home. In this case, the team had been correct in their prediction of her
poor outcome. However, even here it was questionable what value arose from encouraging
Helen to abandon unrealistic expectations in favour of achievable goals. Regardless of this
approach, Helen was still considerably tearful and distressed about her situation when I
visited her three months after her discharge from hospital. While still in hospital, Helen had
interpreted the move towards setting more ‘realistic’ goals as the IDT having given up on her,
and consequentially she believed she gave up on herself too. Of course, this perspective on
the cause of Helen’s poor recovery is highly debatable: Helen had experienced a severe and
extensive stroke. Regardless of the value of keeping positive, she was, as the physician in one
team meeting put it, ‘on a hiding to nothing’. However, the point here is that setting
‘realistic’ goals did not seem to provide her with any great benefit either:
Researcher: I'm interested the physio talked to you about setting a more realistic
goal. When was that conversation?
Helen: A couple of weeks ago and I was very depressed… They obviously
didn't have much faith in me and of course then naturally I didn't either.
Researcher: Yup. Do you think you could have done better if you had focussed on
a different goal?
Helen: I can't think what other goal I could have had 'cos you can't do much if
you can't walk. I've been looking at some of these ladies with their
trolleys and their sticks and I said can't I have one of those, and she [the
physiotherapist] said no, I was not strong enough, legs not strong
enough.
Researcher: Mmm. And what do you think about that?
Helen: Bugger it, let's get them strong.
[Interview with Helen during her inpatient stay]
6.3.6 Financial and organisational drivers for the privileging of goals
It has been mentioned above that privileged goals were strongly associated with an onus
on discharging patients as soon as possible, preferably home to safe, independent living.
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However, it appeared that this emphasis was driven largely by financial and organisational
factors rather than by any particular preference of the clinicians involved. Indeed, many
clinicians expressed a desire to be able to do more work with patients (particularly along
‘patient centred’ lines) if only they had the time allowable. The clinicians expressed a keen
awareness that organisational pressures (such as staffing levels) impacted on the degree to
which they involved patients and family members in goal planning or to which they were able
to work on non-privileged patient-centred goals:
It really falls off the radar a bit. I mean really I should be, as the key worker, I
should be going back after each team meeting and talking to him and his wife
about the goals that we have set, and reviewing them. But that hasn't happened
simply because of time constraints… I do think it's really important, um, I just
can't see how it's possible, like because I have to, I have to get them that bit of
equipment that will make it safe, that - to me that's more of a priority.
(Interview with occupational therapist for George)
Some clinicians spoke of the drive to ‘empty beds’, to discharge people as soon and as
efficiently as possible to their home environments. Goals that did not support this agenda
had, therefore, little influence over the provision of rehabilitation, and thus tended not to
feature in the IDT plan. Higher order goals, relating to the broader issues of quality of life,
faced reductionist treatment in the inpatient environment to transform them into the types of
goals that were privileged by the system.
One physician expressed interest in an approach to goal planning that focused far more
on the life goals of patients. This, he suggested, would require clinicians to engage more with
the people who would support patients following their discharge from hospital, because, in his
mind, the community was the setting where all the real work toward these higher order goals
would occur. According to this view, the job of inpatient clinicians regarding goal planning
should therefore be to equip the patient, their family and any other members of the patient’s
support network in the community (counsellors, ministers, employers and so forth) to identify
and work towards these goals with the patient over time. However, once again, the financial
and organisation systems surrounding inpatient rehabilitation did not appear to support this
kind of approach:
So what we're required to do by the system suits that mechanistic kind of thing,
because we worry about how long the person's going to be here and when they're
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leaving hospital and we don't really want to worry about even what the community
team is going to do… the drivers of the system are, in my opinion, are kind of
largely in conflict with serious goal planning, 'cos to a large extent [publicly]
funded services are finished well before you're, before you're going to see any
achievement of where you're heading for in this sort of goal planning business that
I'm talking about.
(Interview with the physician for Helen)
6.4 Discussion
6.4.1 Privileged versus patient-centred goals in rehabilitation
The aim of this study was to use grounded theory in order to explore how goal planning
was applied in a series of cases involving people receiving interdisciplinary rehabilitation
following stroke. As described above, a substantive theory linking two core themes emerged
from this study: 1) the privileging of certain goal in inpatient rehabilitation and 2) navigation
of the borderlands of patient-centred goal planning. Goal planning appeared to progress most
smoothly, with least problems, when there was an alignment between the goals of the IDT
and the objectives, attitudes and perceived capacity of patients and their family. Conversely,
when the objectives, skills and perceived capacity of patients or family members did not align
with these privileged goals, this resulted in interactional dilemmas for clinicians.
This need to privilege certain types of goals was identified in the research to arise not
due to the personal agenda of any one clinician, but rather as a response to pressures within
the system of publicly-funded rehabilitation: notably to discharge people quickly, safely and
efficiently from hospital (preferably to their home environment). It is questionable therefore
whether a ‘patient-centred’ approach to goal planning in stroke rehabilitation is feasible
within the current funding framework. However, regardless of this financial and
organisational influence on goal planning, the clinicians involved in this study were also seen
to enter patient-clinician interactions with existing ideologies about what should be the
subject of rehabilitation goals: small, easily achievable ‘steps’ regarding (mostly) physical
function. Goal planning appeared to describe the rehabilitation process rather than drive it,
and being ‘realistic’ was more highly valued than being ambitious.
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In the rehabilitation literature, when goal planning is not being used as an individualised
outcome measure it is often presented as a strategy for problem solving and clinical decision
making (McGrath & Davis, 1992; Wade, 1999c). What this research suggests however is that
simply using goal terminology and following goal planning protocol is insufficient to ensure
that the goals set will have any significant influence over the rehabilitation process. Other
drivers, notably the need to fulfil perceptions of professional obligation (such as to provide
particular therapies or to conduct particular assessments) and the need be responsive to
financial and organisational imperatives (such as to reduce length of stay), appear to have
greater influence over the clinical decision-making process than any need to identify and
address what might be genuinely important in the lives of the people receiving the service. In
this study it appeared that, in general, decisions about what intervention need to be provided
were decided on first, with IDT goals to reflect these decisions being set later, rather than vice
versa.
It is also worth noting here that the observed emphasis on ‘realistic’ goals and on
breaking harder goals down into smaller ‘steps’ is an approach that is certainly consistent with
much of the current literature in goal planning in interdisciplinary rehabilitation (Barnes &
Ward, 2000; Holliday, Cano, Freeman, & Playford, 2007; Malec, 1999; McLellan, 1997;
McMillan & Sparkes, 1999; Schut & Stam, 1994; Smith, 1999). However, in this study, the
privileging of these types of goals also appeared at times counter to the ideals of ‘patient-
centred’ goal planning (including those expressed by the clinicians’ involved in this study), as
it limited the scope of what was considered acceptable as patient or family contributions to
goal planning discussions.
The need to discharge patients home also influenced an emphasis in goal planning on
the rehabilitation of physical function. The consequence of this was that rehabilitation
appeared to be more ‘function-centred’ than ‘patient-centred’. While patients and family
members were invited to participate in discussion of goals, clinicians approached the job of
involving family members in goal planning by priming these interactions to be orientated
towards the discussion of physical function. When patient or family goals were expressed
regarding topics not related to physical function, these were converted into short-term goals
about physical function before being included in the IDT plan, or strategies were employed to
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curtail them (such as relegating them to the status of ‘long term goals’ that were thus outside
to scope of inpatient rehabilitation).
The emphasis on physical function and on rehabilitation teams controlling the direction
of the goal planning process is not unique to the services participating in this study. Wressle
et al. (1999) for instance reported in their qualitative study that clinicians had a tendency to
set goals around physical functioning far more than other aspects of health and well-being
(such as psychological or social functioning). They also suggested that this focus was largely
driven by economic factors, in particular, to minimise the average length of hospital stay
(Wressle et al., 1999). Similarly, Playford et al. (2000) suggested that the selection of goals
and interventions for patients tended to reflect the abilities of the rehabilitation team rather
than the specific needs of individual patients. Again, the clinicians in Playford et al.’s (2000)
workshop suggested that patient participation in goal planning was limited to a degree by
organisational constraints, including financial pressure to discharge patients from hospital.
Regarding clinicians controlling the goal planning process, Conneeley (2004) reported in her
qualitative study that clinicians perceived patients to often lack the ability to identify and
articulate goals relevant to rehabilitation, and thus the goal planning became necessarily more
therapist-led than patient-led. Given that the three studies above were conducted in hospitals
in the United Kingdom and Europe, funded by different health systems that the ones operating
in New Zealand, it would appear that the issues which arose in this study regarding limitations
on patient involvement in goal planning cross geographic and institutional barriers.
There are two main responses to this finding that goal planning in inpatient
rehabilitation tended to be more ‘function-centred’ than ‘patient-centred’. The first is to
assume (perhaps from an ideological perspective) that a ‘function-centred’ approach to goal
planning is wrong, and that further work needs to occur in order to develop strategies to make
goal planning in inpatient rehabilitation more ‘patient-centred’ in its orientation. The second
response is to suggest that perhaps a ‘function-centred’ approach to goal planning simply
reflects the financial reality of publicly-funded inpatient rehabilitation, and that true ‘patient-
centred’ rehabilitation is not what these services are funded to provide.
In line with the first response above, Hammell (2006) has stated that ‘enhancement of
function constitutes just one dimension of learning to live well with an impairment’ (p. 127).
A person who has experienced a stroke or a traumatic brain injury does not just have a
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disrupted body; they have a disrupted life. Rehabilitation should therefore be a ‘process of
learning to live well with an impairment in the context of one’s environment… a process that
might include – but cannot be limited to – enhancement of physical function’ (Hammell,
2000, p. 127).
Hammell (2000) has also been critical of the perspective that clinicians are powerless
players in an oppressive health funding system. Feeling powerful and having power are two
separate issues (Peace cited by Hammell, 2000). If approaches to goal planning are so
dependent on financial drivers, then this is a situation which clinicians have largely failed to
challenge ‘because they are the beneficiaries of a status quo that accords them social status,
prestige and power over those who must use their services’ (Hammell, 2000, p. 149).
Although many clinicians might be quick to dispute this assertion, it is interesting to note that
this was also a perspective held by at least one of the patients who participated in this study.
When asked towards the end of his rehabilitation ‘what do you think drives rehabilitation?’
Paul (the Buddhist man with the personal goal to achieve ‘peace and tranquillity’) replied by
rubbing his fingers together, indicating ‘money’. From Paul’s perspective, clinicians engaged
with him in all the activities of inpatient rehabilitation (the showering, the walking, the
assessments and interventions) not because they were primarily motivated to do good work,
but because they wanted to efficiently fulfil the obligations of their job and thus get personal
benefits associated with this.
Despite these political and philosophical arguments however, the alternative opinion –
that a ‘function-centred’ approach to goal planning merely reflects the financial reality of
publicly-funded inpatient rehabilitation – is also compelling. During the period of
observation on both rehabilitation wards, I was aware that there was a fairly constant degree
of staff turn-over, which affected almost all professional disciplines at one point or another.
A vacancy in one group of allied health professionals would leave others scrambling to
backfill the work. In these circumstances, clinical work was cut back to what the health
professionals believed were the fundamental priorities, and, from this perspective, physical
safety in the home environment featured highly and, I would argue, appropriately. To clarify,
broadening the scope of what constituted usual services in inpatient rehabilitation (to perhaps
include, for example, ensuring that a 90 year old woman continued to live a socially enriched
life by developing a strategy to assist her to access the Internet) would ultimately require the
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investment of additional time and resources. While perhaps ideal as an outcome, this time
and these resources would need to come from somewhere. The development of a more
‘patient-centred’ approach to goal planning might therefore be contingent at the very least on
the establishment of a less transitory and larger workforce, and therefore could quite possibly
be a dependent in part on financial solutions.
This type of discussion raises questions about how clinical decisions are made in
inpatient rehabilitation settings. At one level, involving patients and family members in goal
planning takes time. While some have argued that collaborative approaches to clinical
decision making provides additional value in terms of the creation of new knowledge and
solution for clinical problems (Abreu, Zhang, Seale, Primeau, & Jones, 2002; Baker et al.,
2001; Edwards, Jones, Higgs, Trede, & Jensen, 2004), others have stated that strategies for
enhancing patient involvement in goal planning carry with them additional costs in terms of
the clinical time required for appropriate consultation (Jones et al., 2004).
At another level, it would appear that clinical decisions-making is not simply a matter of
determining what is best for the patient from the perspective of the individual’s health and
well-being. An Australian study on decisions regarding access to rehabilitation services
reported that the clinical presentation of individual patients was only one factor influencing
whether or not patients were referred to rehabilitation after traumatic brain injury (Foster &
Tilse, 2003). Other factors influencing referrer behaviour included the organisational and
health care context and the interpretative activities of clinicians making the referral. So, for
example, it was suggested that clinicians who have responsibility for screening patients prior
to referral may ‘alter their interpretations of [clinical] problems depending on the availability
of resources or other organisational and political pressures to ration resources’ (Foster &
Tilse, 2003, p. 2206). Similarly, in terms of goal planning, clinicians might be inclined to
alter their perspectives on what is a relevant and ‘realistic’ goal in inpatient settings based not
only on the patient’s pathophysiology and prognosis, but also on whether or not the relevant
therapies could be provided. This was certainly illustrated in the case of Mary’s, whose
occupation therapist reported that she would not set a goal to work on improving Mary’s
ability to move from a bed to a chair as this would have involved a higher level of staff input
than was easily arranged. This perspective again reinforces the notion that, for the
organisations observed in this study, goal planning tended to describe the rehabilitation
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process rather than drive it. If a rehabilitation service intends to use goal planning to provide
direction in rehabilitation (to influence clinical reasoning), the goals must be set first before
the barriers to goal achievement are investigated and addressed.
6.4.2 Comparing the findings of Chapter 5 and Chapter 6

When comparing the findings in this study to those from the study presented in Chapter
5, there are some similarities but equally a number of differences. To begin with, this latest
study supported the notion (established in Chapter 5) that the term ‘goal’ is used to refer to
not one, but multiple concepts within rehabilitation environments. The distinction between
‘patient and family goals’ and ‘IDT goals’, for example, was made explicit in the way they
were documented in separate parts of the IDT plan. However, individual clinicians, such as
Joyce’s speech language therapist and the doctors in the IDT meetings, also used the term
‘goal’ to refer other aspects of their clinical work that were not necessarily documented as
goals in the clinical notes. Nonetheless, these other ‘goals’ still informed and influence their
involvement in particular cases.
Likewise, this study illustrated how there could be many purposes attributed to goal
planning in rehabilitation, and that while these purposes could interrelate, they could also
conflict. The most dominant conflict that emerged from this latest study was between the use
of goal planning to ‘provide direction’ for rehabilitation and to ‘build a team approach’
(resulting in privileged goals) versus the use of goal planning to enhance ‘patient self-
determination’ and ‘patient empowerment’ (reflecting the ideals of ‘patient-centred’ goal
planning). Further, this study highlighted once more the cognitive dissonance that clinicians
experienced when attempting to balance a need to set ‘realistic’ goals while allowing patients
to retain ‘hope’.
Differences in the findings between these two studies can be largely explained by
differences in the scope of investigation. In Chapter 5, clinicians were asked to talk about
their experiences and perspectives of goal planning for people with any type of acquired brain
injury receiving rehabilitation in inpatient, outpatient, community or residential settings. In
comparison, the study presented in this latest chapter focused just on rehabilitation for people
with stroke in the inpatient wards of publicly-funded hospitals. In New Zealand, people with
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traumatic brain injury (who were included the scope of investigation for Chapter 5, but not
Chapter 6) most often have their rehabilitation funded by ACC: New Zealand’s accident
insurance corporation. Unlike New Zealand’s District Health Boards, who fund stroke
rehabilitation services, ACC has required health professionals to regularly report to case
managers on the goals for individual patients. Thus, goal planning for the purpose of
‘meeting contractual requirements’ featured in the earlier study (Chapter 5) but not in this
most recent one.
In a similar vein, the location of service provision for rehabilitation influenced the
findings in these chapters. The emphasis in this latest study on orienting goal planning
towards discharging people to their home environments clearly is a feature specific to
inpatient rehabilitation, whereas people already in the community do not need to be
discharged anywhere, so other goals will naturally become more prominent. Thus, the
characteristics of privileged goals in this study, which were directly related to discharge
planning, did not feature to the same extent in the study presented in Chapter 5.
Another subtle difference between the two studies was the specific focus of interviews
with clinicians. In the first study (Chapter 5) clinicians were asked to talk in general about
their experiences and perceptions of goal planning in rehabilitation services, whereas in the
second study (this Chapter) clinicians were invited to comment on goal planning as it was
being applied to observed cases. Interestingly the different context of these interviews
appeared to contribute to a slightly different emphasis on the various possible purposes
underlying goal planning in rehabilitation. When asked to talk in general about goal planning,
clinicians commented most often on beliefs regarding the use of goals for the purpose of
providing direction in rehabilitation or for evaluating a patient’s progress and outcome. In
comparison, when asked to talk about goal planning as it was applied to specific cases, the
intention to use goal planning for the purpose of finding out what was meaningful to patients
and their families or to maximise their involvement in rehabilitation planning featured more
highly.
Finally, the findings from the two studies reflect in part the difference between what
people say they do and what they might actually do. In this most recent study, for instance,
there were very few examples of goal planning being used to ‘direct’ the rehabilitation
process or to influence clinical decision making. I also observed a striking difference between
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the stated intent to use goal planning for the purposes of enhancing patient involvement in
clinical decision making and the strategies that clinicians employed to constrain such
involvement. Such observations are a reminder about the limitations of qualitative studies
based solely on the collection of interview data.
6.4.3 Limitations of this study

As with any study, there are some limitations to this research that need to be considered.
Firstly, it is important to reiterate that, because of the qualitative nature of this investigation, it
was not intended and therefore not possible to make generalisations about goal planning in
rehabilitation (Charmaz, 2006). While, as noted previously, the issues identified in this study
were in many ways similar to ones described in other publications (Conneeley, 2004; Playford
et al., 2000; Wressle et al., 1999), these findings are dependent on the context under which
they were collected. The influences of the source of funding, the inpatient location of the
study, and the type of organisational structure are three such variables that have been
discussed in detail above.
In terms of achieving the objectives of this thesis, a more significant limitation relates to
the lack of data specifically gathered regarding the interface between inpatient and
community rehabilitation teams. Thus, while I did gather some incidental data on this topic
during follow up interviews with patients in the community, I did not collect any examples of
correspondence between inpatient and community teams, or any clinical notes or audio-data
from team meetings held in the community setting. These additional sources of information
could have been useful as Cott (2004), in a qualitative investigation of patient’s perspectives
on patient-centred rehabilitation, reported that the transition from inpatient to community
environments is problematic for many people. Furthermore, given that a number of the
clinicians interviewed for my study spoke of some patient and family goals being relevant
only when patients were back in the community, it would have been interesting to examine
how goal planning passed from the inpatient to the community teams (if at all), or how it was
remodelled for patients once they had returned home or had gone into residential care (if
rehabilitation was continued). However, this would have required substantially more data to
be collected on each case once people had been discharged home, extending the scope of this
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investigation. In other words, this would arguably have been another research project
altogether. Further qualitative, observational studies into the application of goal planning in
community rehabilitation services are thus warranted.
A third limitation of this study was the influence of my presence, as researcher, on the
participants’ behaviour. This study was obviously not a ‘blinded’ investigation; all
participants knew what the subject of my thesis was. Furthermore, given the importance
attributed to goal planning in the literature on rehabilitation, it would seem likely
(unavoidable even) that my presence would have resulted in clinicians talking more about
goals in team meetings, involving patients and family members more in discussions of goal
planning, and focusing more on the completion of documentation around goals. Some
clinicians also appeared to want to be helpful in the collection of data for my PhD. For
instance, on one occasion near the beginning of my study, one team member encouraged the
others to ‘speak up’ to improve the quality of my audio-recording during an IDT meeting.
This individual was also known to raise the topic of goal planning far more often in the team
meetings that I attended than in ones that I did not. This was an issue that two of her
colleagues felt obliged to bring to my attention:
Honestly, it frustrates me that because you were sitting in the meeting, probably it
was all about goals, because at most of the other meetings that doesn't happen, um,
so quietly I'm kind of giving my feedback and she's like: ‘What about the goals?
What about the goals?’
(A team member talking about the IDT meetings)
Additionally, the clinicians’ participation in interviews during the rehabilitation process

would have had the effect of encouraging them to reflect more about aspects of their clinical
practice during particular cases, as this was effectively what I was asking them to do in order
to gather data. Thus, interviews with the health professionals could have influenced clinical
decision making and their subsequent interactions with patients and family members. It can
be reasonably assumed however that if my presence influenced the behaviour of clinicians in
any way, it was likely to have done so in a positive direction. In other words, one could
assume that the clinicians in this study were likely to have been on their ‘best behaviour’
regarding goal planning, and that they were undertaking goal planning in a manner that they
felt was most consistent with good practice. This should be a consideration when reading the
findings from this study. However, this conclusion simply serves to make some of the
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findings in this thesis, such as problems with patient and family member involvement in goal
planning and the privileging of certain goals, all the more compelling.
A fourth limitation of this particular study related to the collection of descriptive data
about the research participants. In the presentation of information about the characteristics of
the patient populations, I relied on broad descriptions of pathology (haemorrhagic versus
ischemic aetiology plus side of lesion) and qualitative descriptions of the patients’ disabilities
on initial presentation to the rehabilitation unit. Given that it was never the intention of this
study to make generalisations about how subgroups of patient populations responded to
different types of goal planning, such rough descriptions of stroke severity are perhaps
defendable. However, in retrospect, it might have been more useful for communicating
information about the patients’ presentations if I had used some more standardised tools to
describe the initial severity of each patient’s disability: the Functional Independence Measure,
for instance (Masiero, Avesani, Armani, Verena, & Ermani, 2007; Ng, Stein, Ning, & Black-
Schaffer, 2007).
Similar it may also have been useful for interpretation of these results to have gathered a
little more data about the characteristics of the clinicians who participated in this study. Such
additional data might for instance have included the clinician’s years of experience and
achievement of post-graduate qualifications. However, contrary to this argument, such data
may have been difficult to incorporate into the theory, as judgements would have needed to
have been made about the clinicians’ intentions on the basis of my perception of their
expertise, rather than on the basis of what they said or did. It is interesting to note that one
study of ‘expert practice’ in musculoskeletal physiotherapy has demonstrated that the number
of years of experience a clinicians has does not necessary correlate with expert behaviour or
improved patient outcomes (Resnick & Jensen, 2003).
Finally, there are some limitations to the substantive theory arising from this study that
should be considered. The main limitation here is that this theory is relevant to the
application of goal planning only within the types of rehabilitation services under
investigation. Any alteration to the process or structure of the organisations in these studies
could have easily influenced the characteristic of privileged goals or patient involvement in
goal planning. Other rehabilitation services have in the past attempted to address these very
issues. For example, McGraht & Adams (1999), reporting on the application of goal planning
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at Rivermead Rehabilitation Centre, described the use of tools to identify their patients’ high-
order reference values (e.g. life goals) during goal planning. On the basis of an observational
study involving 82 patients, they concluded that this approach assisted with the alleviation of
anxiety resulting from initial goal failure (McGrath & Adams, 1999). In a similar vein,
Holliday et al. (2007) recently investigated the effects of a novel approach to enhancing
greater patient participation in inpatient goal planning. This approach involved patients
completing a goal planning workbook over a period of time, with assistance from their
inpatient keyworker (Holliday, Cano, Freeman, & Playford, 2007). Holliday et al. (2007)
found that in comparison to patients who received ‘usual practice’, the enhanced approach
resulted in patients experiencing greater satisfaction with the rehabilitation process and that
the goals set were more personally meaningful to them. No differences were observed
however in any measure of functional outcome (Holliday, Cano et al., 2007). Bearing in mind
that both of these studies employed observational rather than experimental methods, these
examples do illustrate that attempts have been made to alter the level of patient involvement
in goal planning. If similar strategies had been applied in a structured manner by the services
involved in my study, it is possible that the characteristics of privileged goals might have been
different. This however is a moot point, requiring further investigation.
6.4.4 Considerations for clinical practice
This research suggests that there are financial, organisational, and ideological barriers to
the implementation of ‘patient-centred’ goal planning in inpatient rehabilitation for stroke. If
rehabilitation teams wish to promote a more ‘patient-centred’ approach to goal planning –
whether or not they should is another debate altogether (Gzil et al., 2007) – they will need to
ensure that they identify and address barriers such as these in their clinical practice. There are
a number of methods that might be of benefit here. A clinical audit, for example, could be
conducted to examine the types of goals that are documented in IDT plans, in order to
examine the emphasis placed on physical function and whether this emphasis is appropriate
for the service being provided, or whether greater attention needs to be placed on other
aspects of life with a disability. The ICF could also be a useful framework for categorising
the subjects of goals in order to track and compare the weighting on various aspects of
functioning over time (World Health Organization, 2001a).
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Clinicians could also examine the way they integrate patient and family goals into IDT
plans. Formal processes for identifying higher-order goals, such as the Rivermead Life Goals
Questionnaire (Nair, 2003), may be useful in this regard. However a conceptual framework
for utilising such goals is also required. McGraht & Adams (1999) have drawn on Carver and
Scheier’s model of goal-directed behaviour in order to suggest a method for incorporating
such higher-order goals into rehabilitation planning, and have suggested that such an approach
might alleviate the distress and anxiety that some patients experience during their recovery
from disability. Likewise, recently a ‘Good Lives Model’ of rehabilitation has been mooted,
which suggests a theoretical framework for linking individual patient’s ‘primary goods’
(deep-rooted natural desires) to the objectives and processes of rehabilitation, including goal
planning (Siegert, Ward, Levack, & McPherson, 2007). Unfortunately, as of yet, no robust
RCTs appear to have been undertaken to test any such hypotheses regarding the integration of
high-order goals into rehabilitation processes (c.f. Chapter 3). Nevertheless, it would seem
axiomatic, at least from this qualitative study, that some more formal incorporation of the
patients’ high-order goals is required if clinicians are genuinely intent on delivering ‘patient-
centred’ rehabilitation.
Finally, a truly ‘patient-centred’ approach to rehabilitation may require a more

significant shift in the way clinicians think about goal planning and rehabilitation. Clinicians
would need to be open to the possibility that anything a patient or family member introduces
during goal planning sessions should, at the very least, be considered for discussion. This
might require clinicians to consider topics outside the traditional scope of inpatient
rehabilitation. It may also require clinicians to consider goals that they deem to be
‘unrealistic’. Given the lack of evidence one way or the other regarding the effect of
achievable versus difficult or challenging goals on patient outcomes (c.f. Chapter 3),
clinicians should investigate their own motives for wishing to set achievable goals, and
consider the possibility that different types of goals may be more appropriate for some
patients in certain contexts. Further discussion of this topic, along with consideration of the
related theme of ‘hope’ is considered in more detail in the following chapter.
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6.5 Conclusion
This chapter has introduced the notion of the privileging of certain goals in inpatient
rehabilitation, and has presented a substantive theory explaining how these privileged goals
create interactional dilemma for clinicians when they do not align with the objectives,
attitudes and perceived capacity of patients and their family. Attempts at engaging with
patients and family members around goal planning were described as entering the
‘borderlands of patient-centred goal planning’. The privileging of goals was seen to be driven
to a large degree by financial and organisation factors. This raised the question of whether a
‘patient-centred’ approach is even possible in inpatient rehabilitation for stroke given the way
it is currently funded and structured.
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Chapter 7: Discussion and conclusions
7.1 Summary of research
The main objective of this thesis was to explore the contribution that inductive analysis
of data from clinical experience and clinical settings could make towards advancing the
development of theory regarding goal planning in rehabilitation. Two grounded theory
investigations were undertaken: one exploring the way clinicians talked about the application
of goal planning to rehabilitation for people with acquired brain injury (Chapter 5), and the
other studying the application of goal planning in a series of cases involving people with
stroke, receiving inpatient interdisciplinary rehabilitation (Chapter 6). These studies were
informed and supplemented by two library-based investigations: a structured review of the
literature investigating the hypothesised purposes and mechanisms attributed to goal planning
in rehabilitation (Chapter 2), and a systematic review, to identify and evaluate the current best
evidence regarding the effectiveness of goal planning to improve outcomes in rehabilitation
populations (Chapter 3).
These studies have resulted in a number of unique contributions to the literature on

goal planning in rehabilitation. In the literature reviews underpinning the empirical studies in
this thesis, I have introduced the notion that, while different purposes for undertaking goal
planning are proposed, these purposes are not necessarily complementary. Different reasons
for using goal planning – such as to measure outcomes, to promote patient autonomy, or to
enhance patient motivation – may require different approaches to maximise the effectiveness
of its implementation. In the systematic review, I concluded that (while some evidence
existed that certain types of goals could influence immediate patient performance on some
tasks, and appeared to positively influence patient adherence to interventions) the evidence
regarding any generalisable effect on patient outcomes was inconsistent at best, and limited
by methodological problems in many of the studies to date. This finding is largely at odds
with the rhetoric around the importance of goal planning in rehabilitation.
Another contribution of this thesis to scientific knowledge has been to closely examine
the use of the terms ‘goal’ and ‘goal planning’ in rehabilitation settings. In my first grounded
theory study in this thesis (investigating clinicians’ talk), I reported that while the clinicians
considered goal planning important, the expressed reasons for valuing goal planning were not
always unclear. The term ‘goal’ referred to not one but many concepts, and goal planning
was used to serve a range of different purposes. Different reasons for undertaking goal
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planning in rehabilitation were interrelated but also at times conflicted, creating the potential
for tensions within the rehabilitation environment.
From the findings in my second empirical study I constructed a substantive theory

explaining a) how certain goals (characterised by short timeframes, conservative estimation of
outcomes, and an orientation to physical function) were ‘privileged’ (i.e. prioritised and
promoted) over others and b) how the involvement of patients and family members in goal
planning appeared to result in interactional dilemmas for clinicians when the objectives,
attitudes and perceived capacity of patients or families did not align with these privileged
goals. Clinicians attempted to resolve these dilemmas by navigating their way through a
discourse of patient-centred therapy while retaining control of the privileged goals of
rehabilitation. As a result, documented team goals appeared to describe rather than drive the
rehabilitation process, compromising the ideals of ‘patient-centred’ rehabilitation.
7.2 Implication for goal theory in rehabilitation

It is a fait accompli that goal planning is a central part of interdisciplinary rehabilitation.
The discourse of goals and goal planning has become deeply rooted in the policies and
procedures of rehabilitation services (Holliday, Antoun, & Playford, 2005; McGrath et al.,
1995; McMillan & Sparkes, 1999; Wade, 1999a), in professional standards (Carswell et al.,
2004; Randall & McEwen, 2000), in clinical guidelines (Baskett & McNaughton, 2003; New
Zealand Guidelines Group, 2006; Schwamm et al., 2005), in contractual and legislative
requirements (Evans, Zinkin, Harpham, & Chaudury, 2001), and in the vocational identity of
professionals working in rehabilitation settings (Wade, 1998).
Despite this entrenching of goal planning in rehabilitation, there has been a lack of
scientific development of goal theory specific to rehabilitation contexts (Siegert & Taylor,
2004). Most often, reported theory regarding goal planning in rehabilitation has been derived
from expert opinion or has been imported from other fields of study (notably industrial-
organisational psychology, sport psychology and education). For example, Holliday et al.
(2005), wrote that: ‘factors shown [my emphasis] to contribute positively to successful goal
setting in rehabilitation are provision of information about condition causing admission,
effective communication and time spent to establish rapport and discuss priorities,
participation, and feedback…’ (Holliday et al., p. 230) However in order to support this
statement, Holliday et al. (2005) cited two narrative reviews of the literature (Schut & Stam,
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1994; Wade, 1998), the results from one workshop on clinicians’ views (Playford et al.,
2000), and three papers from the 1970’s investigating the influence of goal setting on
residential electricity consumption (Becker, 1978), safe performance in a food manufacturing
plant (Komaki, Barwick, & Scott, 1978), and worker behaviour in pulpwood production
(Ronan, Latham, & Kinne, 1973). The point here is that this list of evidence regarding goal
planning in rehabilitation lacks any empirical studies involving populations of people in
rehabilitation services.
Direct application of goal theory from one area of study to another is not without
problems. In fact a good illustration of this can be found in the sport psychology literature of
goal theory. Following the development of goal theory in industrial-organisational
psychology, Locke and Latham proposed that their findings (regarding a linear relationship
between specific, difficult goals and human performance) would be even more pronounced in
sport settings (Locke & Latham, 1985). They based this argument on an assumption that the
measurement of individual performance tended to be more objective in sports compared to
industrial-organisational contexts, and therefore would provide a better basis for goal
selection and evaluation (Locke & Latham, 1985). As it turned out however, scores of
experimental studies into goal theory in sport psychology failed to provide the evidence to
support this assertion (Burton & Naylor, 2002; Hall & Kerr, 2001). Although goal setting
does appear to have a desirable effect on sport performance, the overall effect of specific,
difficult goals has been found to be lower in sport contexts than in industrial-organisational
ones (Burton & Naylor, 2002; Hall & Kerr, 2001). The reason behind this difference
appeared to relate in part to the differences in human cognition and behaviour in sport versus
work contexts. To give just one example, many athletes are already driven by their own
superordinate goals (such to win a competition or achieve a personal best). The addition of
specific, difficult goals on top of these superordinate goals therefore does not have the same
effect as it might do in a work setting, where employees are not internally driven to the same
extent (Hall & Kerr, 2001). Thus, Hall and Kerr (2001) have stated that: ‘While there is little
doubt that goal setting is an effective performance-enhancing technique, claims for its
effectiveness as a motivational technique must also consider the context in which participants
are being asked to set goals’ (p194). This argument, it would seem, should equally apply to
goal planning in rehabilitation settings.
It is beneficial therefore to examine the unique features of goal planning in a

rehabilitation context, in order to consider how these might influence the development of goal
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theory specific to this area of inquiry. The results from this thesis provide substantial
contribution to scientific knowledge in this regard. For example, the studies in this thesis
have demonstrated how in rehabilitation there are a number of stakeholders who may have not
only different goals for a single episode of rehabilitation, but also different perspectives on
what the main purpose of goal planning in rehabilitation should be. Patients, family
members, the various clinicians, and even, in some case, the funders of rehabilitation services,
may all enter into the goal planning process from different perspectives. Indeed, goal
planning emerged in Chapter 5 as a potential technique for identifying and confronting
different perspectives regarding the intent of providing and receiving rehabilitation
interventions. Compare this with an industrial-organisations setting where goals (or at the
very least, the focus of goals) are largely imposed on employees by an authority figure, and
where such imposition may even be expected by workers.
In rehabilitation, in comparison to industrial-organisational psychology, it is also

unclear exactly who the goals are for. As concluded in Chapter 5, the term ‘goal’ in a
rehabilitation context is used to refer to a range of different constructs. Goals can be seen as
tool for motivating patients (Evans & Hardy, 2002; Gauggel & Hoop, 2004) or for directing
the attentions of clinical team members (Playford et al., 2000; Schut & Stam, 1994).
Conversely however, findings from the second qualitative study in this thesis would suggest
that current approaches to goal planning may have very little influence over the actual
rehabilitation process. It was observed that documented goals in interdisciplinary inpatient
settings tend to describe rather than drive the rehabilitation process. It is debatable whether
alternative approaches to goal planning could (or should) alter this, but regardless, the point
here is that the involvement of multiple stakeholders with different agendas is a characteristic
of rehabilitation that may not be so pronounced in other environments.
A third unique aspect of goal planning in rehabilitation, and one which proved
troublesome for many of the participants in my research, related to problems around the
prognosis of outcome. Prediction of outcome after acquired brain injury, while feasible at a
population-level, is difficult at an individual patient-level. A good predictor of outcomes for
people with stroke, such as the ‘six simple variables’ model, can often only predict very gross
outcomes, such as being ‘alive and independent’ (Counsell, Dennis, & McDowall, 2004).
There is also always some variability in the accuracy of such prognostic tools, which make it
difficult to predict how individual people will respond to rehabilitation interventions. For
example, one of the patients participating in this research (Mary) greatly exceeded her
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clinically-predicted outcomes. This relatively high degree of variability in outcomes
following acquired brain injury makes decisions regarding what should be a goal in
rehabilitation settings more challenging than it perhaps is in other contexts (such as sport or
industrial-organisational settings). Furthermore, this problem with prognosis exists regardless
of whether clinicians are trying to set easily achievable or more challenging goals.
Other unique aspects of goal planning in rehabilitation for people with acquired brain
injury include: the involvement of people who may have language or cognitive impairments;
the intention to use goals to achieve secondary gains (such as assisting people to come to
terms with a newly acquired disability or to address problems with self-awareness); and the
wide range of issues related to health and well-being to select from when attempting to decide
what the focus of goal planning should be. In other words, it is an over-simplification to
assume that goal theory from non-health related fields of study can be transplanted directly
into a rehabilitation context without modification. It is equally problematic to cite research
from experimental psychology involving people without disabilities as evidence for the
effectiveness of specific approaches to goal planning in clinical rehabilitation. Thus, far more
rehabilitation-specific research into goal theory needs to be undertaken. Suggestions for such
research, in conjunction with further discussion of specific issues arising from this thesis, are
presented below.
7.2.1 Motivation, hope, and goal difficulty
Motivation, hope and goal difficulty were three related themes arising in both
qualitative studies in this thesis. In particular, the clinicians in these studies experienced
difficulties balancing the perceived need to set ‘realistic’ goals with a desire to allow patients
and family members to retain hope.
In fact, goal planning, motivation and hope appear to be intrinsically linked constructs
(Miller, 2007; Snyder, Lehman, Kluck, & Monsson, 2006). Synder et al. (2006) defined hope
as ‘a positive motivational state that is based on an interactively derived sense of successful
(a) agency (goal-directed energy), and (b) pathways (planning to meet goals)’ (p. 89). It
would seem difficult therefore to talk about goal planning without considering the notion of
hope and motivation.
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Synder et al. (2006) has suggested that people with high dispositions towards hope are
likely to do better in rehabilitation settings, because they are better at coping with adversity
and tend to engage more in actions related to pursuing their goals. Hope is generally
considered an important factor when coping with negative life events (Popovich, Fox, &
Burns, 2003), thus could be considered an essential factor for successful rehabilitation.
Furthermore, clinicians, it would seem, have the ability to both positively or negatively
influence a patient’s level of hope (Synder et al., 2006). For example, telling a patient that
their goal is ‘unrealistic’ may have a strong negative influence on that patient’s disposition
towards hope (as was the experience of Helen in my second qualitative study).
Miller (2007) argues that how clinicians conceptualise hope underpins how they
perceive strategies to influence it at various stages in health and illness. For instance, some
clinicians refer to ‘false hope’ in situations where ‘hope’ is conceptualised in terms of a
probability of outcome (rather than a personal disposition or world-view) and when the
clinicians’ estimation of prognosis is incongruent with the goals of patients and their family.
The interesting issue here is that clinicians may be more risk-adverse when it comes to setting
unlikely or difficult goals than are patients and their family members (although this in itself is
a hypothesis worth testing). A frequent strategy employed by the clinicians in the two
qualitative studies in this thesis, to deal with challenging or difficult goals, was to break them
down into ‘small steps’ (which then featured as the privileged IDT goals). This is an opinion
that is not uncommon in the rehabilitation literature (Holliday, Cano et al., 2007; Malec,
1999; McMillan & Sparkes, 1999).
It is however an assumption that progressing rehabilitation in small ‘realistic’ steps

achieves the best possible outcome for patients. A recent study by Horn et al. (2005) has
resulted in some findings that appear to contradict this hypothesis. This paper was one part of
a very large prospective observational cohort study, involving five inpatient rehabilitation
facilities and 1291 patients with moderate to severe stroke (Gassaway et al., 2005). In Horn et
al.’s (2005) paper, the authors used regression analysis to examine the relationship between
all data concerning patient characteristics, rehabilitation activities (including types of
interventions and hours of contact), medications and nutritional support, and the timing of
interventions, with patient outcomes on discharge (Horn et al., 2005). Controlling for
confounding variables, Horn et al. (2005) reported that for people with moderate to severe
disabilities on admission to rehabilitation, one of the best predictors of better functional
outcomes on discharge was earlier participation in higher-order, challenging therapy activities
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(such as gait retraining for people who have difficulty with sitting balance or bed mobility).
This finding applied regardless of the severity of the patients’ disability. The implication of
this research, if correct, is that people presenting on admission with no functional mobility
should, within the first few sessions, be started on early and aggressive mobility retraining
(with whatever physical support is required to make this a possibility). Horn et al. (2005)
noted that this finding directly challenged the traditional perspective that patient should
progress through rehabilitation in a stepwise manner with progress onto more challenging
activities being delayed until basic functional skills had been mastered.
Returning to the topic of this thesis, in addition to any physiological explanation for
Horn et al.’s (2005) finding, it seems likely that this approach to rehabilitation might have a
psychological impact as well. Consider Helen’s response in hospital to being told to lower
her expectations regarding to goal to walk: ‘I was very depressed… They obviously didn't
have much faith in me and of course then naturally I didn't either.’ In other words, despite
their hegemony, it is possible that ‘realistic’ goals can sometimes have a deleterious effect on
patient hope and therefore on their motivation, coping and ability to strive for greater
improvements.
In fact, we currently have very little empirical evidence about the relationship between
hope, motivation, personal striving, and health outcomes for rehabilitation patients. There are
therefore a number of research questions that have yet to be explored in experimental studies
in this regard. For instance: How do patients respond in post-acute interdisciplinary
rehabilitation to very difficult or challenging goals? What are the social and psychological
consequences of patients failing to achieve specific goals? Are patients less well prepared for
poorer outcomes if they have been encouraged to pursue difficult or challenging goals? Is it
possible to train patients (or clinician’s even) to have a more hopeful disposition and what
would be the effect of this on rehabilitation outcomes? Are there any personal factors which
influence the response of individual patients to the level of goal difficulty (or other variables
associated with goal planning)?
In terms of this last question, it is worth returning once more to the literature in sport
psychology. Separate to the investigation of Locke and Latham’s (2001) goal theory in sport
psychology, there has been the development of ‘Achievement Goal Theory’. Research into
this theory has sought to explore (among other things) the influence of individual goal
dispositions on sport performance under various conditions (Duda, 2001). Two central goal
dispositions include a ‘task orientation’ and an ‘ego orientation’. People who score highly on
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measures of task orientation tend to define success in sports in terms of their personal learning
and effort, whereas people with an ego orientation define success more in terms of publicly
demonstrated achievement in comparison to other (Duda, 2001). Goal orientations are said to
be orthogonal: in other words, some individuals score high in both task and ego orientations,
while other might score low in both or have a mixed response to questionnaires evaluating
such personal attributes (Duda, 2001).
It is interesting to consider whether patients might also enter into the rehabilitation
environment with individual orientations towards different types of goals. While, it would
seem somewhat irrelevant to test Achievement Goal Theory in rehabilitation environments, (it
is hard to immediately conceptualise how an ego orientation would translate in a hospital
setting), further exploration of goal dispositions in clinical populations would appear to be of
value. In this regard, because of the novelty of the research question, a qualitative research
methodology might be the best way to start, perhaps by interviewing patients exposed to a
range of different types of goal planning. Future research could be conducted to see if it
would be possible to development more specific approaches to goal planning that were
individualised to personality types.
7.2.2 Goal planning and family involvement in rehabilitation
This thesis also has contributed new knowledge regarding the involvement of family
members in goal planning for rehabilitation. The concept of involving family members in
goal planning itself is not new (Becker et al., 1974). There have been many hypothesised
benefits associated with it. It is believed that family members are more likely to be willing
and able to support the rehabilitation team in their work if they are involved in the goal
planning process from the beginning of admission (Becker et al., 1974; Lefebvre, Pelchat,
Swaine, Gélinas, & Levert, 2005; Sohlberg, McLaughlin, Todis, Larsen, & Glang, 2001;
Visser-Meily et al., 2006; Wade, 1999c). It has also been speculated that family members are
in a good position to assist patients with the transfer of skills and knowledge acquired in the
inpatient environments to the home setting (Becker et al., 1974; McMillan & Sparkes, 1999).
The involvement of family members in goal planning has also been raised as a strategy for
early identification of family expectations regarding patient outcomes, allowing debate of
these expectations to occur if need be (Becker et al., 1974; Carswell et al., 2004; Sohlberg et
al., 2001; Wade, 1999a). Finally, it has been suggested that family members can represent
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patient perspectives on goal planning in situations where patients are not capable of
advocating for themselves (Law et al., 2005; McClain, 2005; McGrath et al., 1995; Randall &
McEwen, 2000; Wade, 1999a).
The results from the two qualitative projects in this thesis contribute additional
knowledge on this topic. The previously hypothesised benefits associated with involving
family members in goal planning were reiterated in interviews with clinicians in this thesis.
The involvement of family members in goal planning was reported by clinicians to both a)
direct the team towards issues that were important to family members and b) direct the family
away from issues that were seen to be outside the scope of rehabilitation. Goal planning was
viewed by some clinicians as a tool for educating family members about the rehabilitation
process and to encourage them to ‘buy-in’ to rehabilitation strategies.
However, in this thesis it also emerged that the involvement of family in goal planning
could also result in additional challenges for health professionals. Family members were seen
to have their own agendas and emotional responses to the patients’ situation, and at times
clinicians viewed the involvement of family members as potentially disruptive to the setting
of clinically-relevant goals. In the interviews for the first qualitative study, some clinicians
expressed the opinion that the involvement of family members in goal planning could
potentially be a barrier to the development of a working relationship with the patients, as well
as a potential source of time-consuming conflict. Clinicians reported responding to these
problems by talking issues through with the family members in question. However, at times,
clinicians also addressed these issues by implementing strategies to limit the involvement of
family members in goal planning.
Arguably, the rehabilitation of personal relationships following brain injury should

equally be a consideration for the IDT as is the rehabilitation of physical function (Hammell,
2006). Family functioning is often threatened after one family member experiences a brain
injury, and the family of people with brain injury are known be at risk of depression, marital
problems, physical health problems, and poorer quality of life (Gan, Campbell, Gemeinhardt,
& McFadden, 2006; Man, Lam, & Bard, 2003). Furthermore, in New Zealand where this
research was undertaken, it is a core requirement in He Korowai Oranga (the national Māori
Health Strategy) that health care services implement policies which strengthen families
(Ministry of Health, 2002). It has been argued, for similar reasons, that a family systems
approach to brain injury rehabilitation should be employed (Visser-Meily et al., 2006).
212
Again, however, it would appear there are organisational barriers to the implementation
of a more family-systems approach to rehabilitation. In additional to the emphasis noted on
physical (as opposed to social or psychological) functioning, rehabilitation systems also tend
to centre all funding on the individual patient (rather than on the family unit). It is interesting
to note that the literature on goal planning in rehabilitation also tends to exclude family
members from being the focus of rehabilitation interventions. McMillan & Sparkes (1999)
for instance wrote that ‘goals may involve the patient and the relative but there cannot be
[goals] which are set for relatives/carers to achieve alone, independent of the patient; these
would be plans of action’ (p. 244). Likewise, Randall and McEwen stated: ‘All family
members and significant other may be involved in goal setting and with the patient’s care,
goals may involve them, but they are not the focus of the goal’ (p. 1200).
A family systems approach to rehabilitation, such as suggested by Visser-Meily et al.

(2006), would therefore require a fairly large alteration in the way goal planning is
conceptualised. However, maybe a ‘family-centred’ approach to goal planning rather than a
‘function-centred’ or even a ‘patient-centred’ approach would achieve more sustainable, long-
term outcomes. This is yet another area for further investigation in the future.
7.3 Limitations of the research and future directions

Although the limitations of each study have been addressed in the preceding chapters, it
is beneficial here to consider the limitations of this work as a whole. The original aim of this
research was to use inductive methods in order to further the development of goal theory
specific to rehabilitation. During the early days of this thesis, I speculated about the
possibility of developing a preliminary framework for a unified theory of goal planning in
rehabilitation, even if this was limited to only a very specific area of clinical work, such as
inpatient rehabilitation for brain injury. However, as this thesis progressed, it became more
and more clear that such a unified theory was a long way off, if at all feasible. In fact, what
this thesis has shown is the extraordinary range of variables for consideration when discussing
goals and goal planning in rehabilitation. Each of the variables (e.g. the purpose of goal
planning, the level of difficulty of goals, the meaningfulness of goals, the way team members
share goals, the way family members are involved, the influence of funding structures etc.)
could be the subject of a whole raft of future studies.
213
As mentioned in the discussion sections of both Chapter 5 and Chapter 6, one major
limitation of the research in this thesis arose from the chosen method of inquiry. Grounded
theory, like any other qualitative methodology, focuses on exploring the idiographic, and
therefore the findings resulting from it are not necessarily generalisable to other contexts
(Charmaz, 2006). Firstly, these studies were conducted in New Zealand, and therefore are
greatly influenced by the clinical culture and funding structures of this region. In other
countries, the emphasis on contractual requirements for goal planning may well be different,
and therefore influence the purposes for goal planning to a greater or lesser extent. On the
other hand, many of other findings, particularly in the second study in this thesis regarding the
impact of financial influences on goal planning, do in fact appear to be supported by studies
from other countries (Conneeley, 2004; Playford et al., 2000; Wressle et al., 1999).
Secondly, as mentioned in Chapter 6, the results from this thesis reflect, in part, the
policies and practices of the organisations who participated in the research. It is possible that
studying goal planning in other centres might have resulted in different findings. In particular,
future research on goal theory in rehabilitation would benefit from similar studies being
conducted in community-based settings or for other patient populations (such as mental health
rehabilitation or spinal injury rehabilitation).
Thirdly, while opportunities were sought in my last study, wherever possible, to select
patients from non-European backgrounds, the patient mix for this study did not reflect the
cultural diversity of New Zealand. Furthermore, my analysis of the data from these studies
was limited to my own cultural interpretations. There are a number of research questions
regarding how people from different ethnicities engage with clinicians around goal planning
that I was unable to explore in detail in my study. It would of benefit in the future to
undertake research in order to specifically study the way different cultures understand and
engage in goal planning with clinicians. However, for this type of study a Participation
Action Research methodology (Brydon-Miller, 1997) or a Kaupapa Māori (Cunningham,
2000) methodology might be more appropriate.
Finally, this thesis really only represents the beginning of a whole programme of work
investigating the application of goal planning in rehabilitation. It has provided considerable
direction for future research initiatives, but further work needs to be done to develop goal
theory specific to rehabilitation. In addition to further qualitative research, as described
above, it would seem extremely worthwhile to undertake quantitative studies in order to
explore the details of goal theory in rehabilitation contexts. One approach to this would be to
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undertaken more laboratory-styled research, testing how rehabilitation patients respond to
different approaches to goal planning. This could involve establishing a mock-rehabilitation
environment (for example treadmill training for people with post-acute stroke, or exercise
therapy for people with chronic obstructive pulmonary disease), with the intention of
manipulating individual variables associated with goal planning (e.g. goal specificity, goal
difficulty, goal meaningfulness, feedback on goal achievement etc.) to test the affect on
patient performance and outcomes. Such studies could also explore patient characteristics
(e.g. goal dispositions, their self-efficacy etc.), and the influence of these factors on goal
effects.
7.4 Self-reflection on the research process
One anomaly in the presentation of the methodology employed for this thesis (c.f.
Chapter 4) is the inclusion of references that were published during the production of the
research (Charmaz, 2006; Duchscher & Morgan, 2004; Hallberg, 2006; Heath & Cowley,
2004; Mills et al., 2006; Walker & Myrick, 2006). In fact, one of the key methodology texts
referred to through this thesis was published after the completion of the first qualitative study
described in Chapter 5 (Charmaz, 2006). It would appear that the debate (both for me, but
also internationally) around my methodology of choice continued to evolve during the course
of my PhD. At the beginning of my PhD, I was referring to Strauss & Corbin’s (1998) text as
my main methodology guide. However, I had equally been influenced by Crotty’s (1998)
explanations regarding the philosophy underpinning constructivist epistemology, and this
seemed at odds with aspects of Strauss & Corbin’s (1998) approach to grounded theory (c.f.
Chapter 4). My response at this stage was to choose the aspects of Strauss & Corbin (1998)
that fitted my constructivist leaning, and ignore the rest. It was not until I came across
Charmaz’s (2000, 2003, 2006) publications that I had the resources to fully articulate what I
was attempting in my research. Thus, the emergence of constructivist grounded theory during
the last five to ten years has mirrored my own development as a researcher.
There is one issue however that has yet to be discussed in the literature on
constructivist grounded theory, and that is to do with the need to develop a core category or
core variable in grounded theory research. This is an issue which some researchers in the past
have stated is a necessary part of a completed grounded theory study. For example, McCann
215
and Clark (2003a) state that for ‘an emerging theory to be integrated, dense and saturated, a
core category (or core variable) must be present’ (p14).
However, the insistence on one core category is arguable based on critical realist
ontology, as it requires a belief that for any area of social inquiry there is one central variable
of importance from which all others must arise. In the research for this thesis however, I felt
it was presumptive to assume the research would not be complete until I had identified one
core category. Indeed for my last (and largest) study, I constructed two core categories.
Perhaps I could have continued with the construction of my findings until I had only one
theme, with maybe one of the themes growing to incorporate the other, or maybe some
superordinate theme being developed to encapsulate them both. However, these options
seemed disingenuous, and would have been pursued only to meet some preconceived notion
of what the results of a grounded theory study were suppose to look like.
Interestingly, Charmaz (2006), in her most recent textbook, is silent on the topic of core
categories in constructivist grounded theory. However, one of her arguments has been that
researchers should be able to use the methods of grounded theory without having to subscribe
to the 20th Century, post-positivistic leanings of it co-creators. This, it would seem, includes
the requirement for a core category. (K. Charmaz, personal communication, June 14, 2007).
7.5 Conclusions
This thesis has explored in depth the concepts of ‘goals’ and ‘goal planning’ in
rehabilitation. It has demonstrated that goal planning in rehabilitation for people with
acquired brain injury is perhaps far more complicated than has previously been presented in
the literature. The thesis has also illustrated that the establishment of a scientific basis for
goal planning in rehabilitation will require the development of a new body of research
specific to rehabilitation contexts, rather than just assuming that research from other fields can
be imported without modification or modified without further investigation. I have also
introduced in this thesis the notion that there are multiple purposes associated with goal
planning in rehabilitation and have demonstrated how these purposes can both interact and
conflict. I have presented a substantive theory, grounded in data from observations and
interviews in clinical settings, to explain how the various stakeholders involved in inpatient
rehabilitation for stroke (the patients, their family members, and the clinicians) interact
around goals and goal planning. This theory provides a framework for understanding how
216
certain types of goals become privileged by the rehabilitation system and how the privileging
of such goals can conflict with the ideals of ‘patient-centred’ rehabilitation.
This body of work has multiple applications. At the level of international research, the
findings from this thesis can be used to guide the development of a shared lexicon of
terminology to describe the parameters of goals and goal planning in rehabilitation, with the
objective of enhancing our ability to operationally describe and compare different approaches
to goal planning under investigation. The work presented in the systematic review for this
thesis also provides guidance regarding how to improve the quality of quantitative
investigations into the effectiveness of goal planning to influence rehabilitation outcomes.
Finally, multiple research questions have emerged from this thesis for future work, including
(but not limited to) whether a ‘family-centred’ approach to goal planning would be better than
a ‘patient-centred’ or ‘function-centred’ one (and to determine what a ‘family-centred’
approach might look like), whether patients (and clinicians) would strive for and achieve
better outcomes if presented with more ambitious compared to easily achievable goals (and
what the consequences of doing so might be), and whether it is possible to identify personal
goal dispositions in rehabilitation contexts that moderate the effectiveness of traditional or
alternative approaches to goal planning.
In terms of the clinical application of this work, interdisciplinary teams could use the
results from this thesis to guide the development of a shared understanding of goal planning
within their own teams. Clinicians may also find this thesis useful for critically appraising
their own clinical work and for challenging themselves as to whether their current service
approach to goal planning matches their stated intentions, particularly regarding ‘patient-
centred’ rehabilitation or the use of goals to drive (versus merely describe) their clinical
decision making.
Goal planning in rehabilitation for people with acquired brain injury is a complicated,
multi-variable process. The longstanding belief that goal planning in interdisciplinary
rehabilitation is both fundamental and commonplace has perhaps served to reinforce a notion
that effective goal planning can be achieved simply by having good intentions and following
efficient work practices. The findings from this thesis challenge this perspective and provide
a foundation for future research in this area of study.
217
Glossary
Acquired brain injury: An ‘injury to the brain, commonly caused by trauma, stroke, hypoxia
or infection, that results in a deterioration in cognitive, physical or emotional function which
may be temporary or permanent.’ (Harris et al., 2006, p. 21)
Activity: The ‘execution of a task or action by an individual’ (World Health Organisation,

2001a, p. 14).
Activity Limitation: ‘Difficulties an individual may have in executing activities’ (World

Health Organisation, 2001a, p. 14).
Body function: The ‘physiological functions of body systems (including psychological

functions)’ (World Health Organisation, 2001a, p. 12).
Body structure: The ‘anatomical parts of the body such as organs, limbs and their
components’ (World Health Organisation, 2001a, p. 12).
Collaborative goal planning: A term adopted for the purposes of this thesis to refer to any
approach to goal planning in rehabilitation whereby goals are selected through some process
that involves consultation and discussion of those goals with the patient.
Constant comparative method:
A method of analysis that generate successively more abstract concepts and

theories through inductive processes of comparing data with data, data with
category, category with category, and category with concept. Comparisons then
constitute each stage of analytic development. (Charmaz, 2006, p. 187)
Constructivism: An epistemology that ‘truth, or meaning, comes into existence in and out of
our engagement with the realities in our world’ (Crotty, 1998, p. 8). Constructivism is:
A social scientific perspective that addresses how realities are made. This
perspective assumes that people, including researchers, construct the realities in
which they participate. Constructivist inquiry starts with the experience and asks
how members construct it. To the best of their ability, constructivists enter the
phenomenon, gain multiple views of it, and locate it in its web of connections and
constraints. Constructivists acknowledge that their interpretation of the studies
phenomenon is itself a construction. (Charmaz, 2006, p. 187)
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Credibility: A criteria for against which a grounded theory study can be critically evaluated.
Credibility refers to how believable the research process, data analysis and breadth of the final
theory is (Charmaz, 2006).
Critical realism: An ontological perspective that assumes a ‘real’ reality exists, but that this
reality can only ever be imperfectly perceived (Mills et al., 2006). In other words, critical
realists believe that there is a world and a reality that exists outside of human consciousness,
but that human consciousness is limited in its ability to completely comprehend them.
Data saturation: A grounded theory term referring to a point during analysis when the
collection of further data is unlikely to reveal any new direction, any new questions or any
reason to sample data further (Morse & Richards, 2002). (This term is used synonymously
with the term ‘theoretical saturation’.) The decision regarding when data saturation has been
reached appears however to be a subjective one (Hallberg, 2006). There is no external way of
confirming when data saturation has been reached, because there is no way of truly knowing
what new data would reveal until it is collected.
Disability: The ‘umbrella term for impairments, activity limitations or participation

restrictions’ (World Health Organisation, 2001, p. 3).
Epistemology: The study of knowledge. Epistemology relates to one’s beliefs regarding the
nature of knowledge and how it is possible to know what we know. (Crotty, 1998).
Fit: A criteria for against which a grounded theory study can be critically evaluated. Fit
refers to the degree to which the categories or themes in a grounded theory study emerge from
the data rather than from some pre-established theory or other source (Lomborg & Kirkevold,
2003). Lomborg and Kirkevold (2003) noted that ‘fit’ forms a basis for other criteria for
critical evaluation of grounded theory studies: namely ‘work’, ‘relevance’, and
‘modifiability’. They also noted that interpretation of ‘fit’ is dependant in part on underlying
beliefs regarding ontology and epistemology (Lomborg & Kirkevold, 2003).
Functioning: The ‘umbrella term encompassing all body functions, activities and
participation’ (World Health Organisation, 2001a, p. 3).
Goal planning by proxy: A term adopt for the purposes of this thesis to refer to any
approach to goal planning in rehabilitation whereby clinicians involve a third party,
previously close to the patient and usually their next-of-kin, to assist with the selection of
219
rehabilitation goals. In adult rehabilitation, this usually occurs because the clinicians wish to
involve the patient in collaborative goal planning, but there are restrictions on doing so due to
the patient’s cognitive or communicative impairments.
Goal: A term with multiple possible interpretations. See Section 1.2 of this thesis (pages 3-4)
for further details.
Goal planning/goal setting: A term with multiple possible interpretations. See Section 1.2 of
this thesis (pages 4-5) for further details.
Impairment: The ‘problems in body function or structure as a significant deviation or loss’

(World Health Organisation, 2001a, p. 12).
Interdisciplinary team:
An interdisciplinary team is characterized by joint activity, collaboration, the

beginnings of shared linguistic practices, and shared responsibility (Sands cited in
Opie, 2000). The outcome is accomplished by interactive work, contributions
requiring attention to team process (Bailey cited in Opie, 2000), and the
development of an action consensus as a way of focusing on task and maintaining
group activity. (Opie, 2000, p. 39-40).
Modifiability: A criteria for against which a grounded theory study can be critically
evaluated. The modifiability of a theory referred to the capacity that it has to change to
accommodate new data if such data later emerges (Lomborg & Kirevold, 2003).
Multidisciplinary team:
A multidisciplinary team is characterized by parallel work. Each discipline

operates independently of the others. There are infrequent meetings, and the
dominant work relationship is one in which one member’s contribution is little
affected by the input of others... This model of teamwork tends to be seen as the
least productive (an issue with considerable organizational implications for those
establishing multidisciplinary teams. (Opie, 2000, p. 39)
Objectivism: An epistemological position that ‘things exist as meaningful entities

independent of consciousness and experience, that they have truth and meaning residing in
them as objects (objective truth and meaning, therefore), and that careful (scientific?) research
can attain that objective truth and meaning. This is the epistemology underpinning the
positivist stance.’ (Crotty, 1998, p. 5-6)
220
Ontology: The study of being and existence. Ontology relates to how one perceives the
nature and structure of reality, and in social science, the nature and structure of social reality
(Crotty, 1998).
Originality: A criteria for against which a grounded theory study can be critically evaluated.
Originality refers to how novel the work resulting from a grounded theory study is.
Originality can be judged on the basis of whether it produces new perspectives, as opposed to
being a re-packaging of pre-established concepts (Charmaz, 2006).
Participation: The ‘involvement in a life situation’ (World Health Organisation, 2001, p. 14).
Participation restriction: The ‘problems an individual may experience in involvement in life

situations’ (World Health Organisation, 2001, p. 14).
Positivism:
…an epistemology that subscribes to a unitary scientific method consisting of

objective systematic observation and experimentation in an external world. The
goal of positivistic inquiry is to discover and to establish general laws that explain
the studied phenomena and fro which predictions can be made. Subsequently,
experimentation and prediction can lead to scientific control over the studied
phenomena. (Charmaz, 2006, p.188)
Post-positivism: A theoretical perspective regarding science based on an objectivist

epistemology and critical realist ontology (Crotty, 1998). Post-positivism arose from a
reaction to the divide between positivist dogma and observed scientific behaviour (Crotty,
1998). In particular, it was noted that while positivism required all scientific statements to be
verified by observation before being accepted as meaningful, many scientific theories
appeared to be constructed and accepted without such observational data (e.g. theories
regarding subatomic particles). Post-positivism is characterised by Karl Popper’s falsification
principle and the process of hypothetico-deduction (Crotty, 1998). Instead of scientific theory
being established by induction based on observation of data (the positivist approach),
Popper’s scientific method progressed as follows: ‘(a) scientific theories are proposed
hypothetically; (b) propositions are deduced from these theories; and (c) the propositions are
then tested, that is, every effort is made to prove them false’ (Crotty, 1998, p.32). In this way,
scientific theory from a post-positivist perspective is never taken as ‘truth’ and is always
conditional.
221
Prescribed goals: A term adopted for the purposes of this thesis to refer to any approach to
goal planning in rehabilitation whereby goals are set for patient by a health professional
acting as an authority figure.
Purposeful sampling: An approach to selection of participants or sources of data on the basis

of their characteristics. Purposeful sampling is most often used at the beginning of a
grounded theory investigation in order to ensure a wide range alternative perspectives are
represented in the data for analysis. However it is replaced by theoretical sampling as a study
progresses (Morse & Richards, 2002; Charmaz, 2006).
Realism: An ontological perspective that assumes a ‘real’ reality exists, and that this reality
exists outside the conscious mind (Crotty, 1998). Realism can be contrasted with the
ontological perspectives of ‘idealism’: the worldview that reality is solely a product of the
mind and ideas (Crotty, 1998).
Rehabilitation: A ‘process aimed at enabling persons with disabilities to reach and maintain
their optimum physical, sensory, intellectual, psychiatric and/or social functional levels, thus
providing them with the tools to change their lives towards a higher level of independence.
Rehabilitation may include measures to provide and/or restore functions, or compensate for
the loss or absence of a function or for a functional limitation. It includes a wide range of
measures and activities from more basic and general rehabilitation to goal-oriented activities,
for instance vocational rehabilitation. The rehabilitation process does not, however, involve
initial medical care.’ (World Health Organisation, 2001, p. 290)
Relativism: An ontological position that what is said to be reality is really just ‘the sense we
make of them’ (Crotty, 1998, p. 64). This perspective assumes that ‘different people may
well inhabit quite different worlds’ (Crotty, 1998, p. 64). Symbolic interactionism, the
theoretical perspective underlying grounded theory, has been said to require relativist
ontology, as the investigator using symbolic interactionism is required to consider their data
from the standpoint of those studied. (Crotty, 1998).
Relevance: A criteria for against which a grounded theory study can be critically evaluated.
The relevance of a theory can be analysed by examining its significance in terms of actions
and processes in the area of study (Lomborg & Kirkevold, 2003).
Research Method: The specific techniques used for conducting a study, including methods
of data collection and analysis (Crotty, 1998).
222
Research Methodology: The ‘strategy, plan of action, process or design lying behind the
choice and use of particular [research] methods and linking the choice and use of methods to
the desired outcome’ (Crotty, 1998, p. 3).
Resonance: A criteria for against which a grounded theory study can be critically evaluated.
Resonance relates to the degree with which a study is meaningful to people or situations
outside the immediate scope of the lives of the individual people who participated in the study
(Charmaz, 2006).
Stroke: An ‘abnormal condition of the brain, characterised by occlusion by an embolus,

thrombus, or cerebrovascular haemorrhage or vasospasm, resulting in ischemia of the brain
tissues normally perfused by the damaged vessels’ (Harris et al., 2006, p. 330). Stroke is also
known as a ‘cerebrovascular accident’.
Subjectivism: An epistemological position that the nature and existence of reality (and all
objects in reality) is solely the product of the subjective experience. Crotty (1998) made this
distinction between subjectivism and constructionism: In constructionism, meaning (and
truth) is created from the interaction between conscious beings and things in the world,
whereas in subjectivism, meaning is create independent of the things in the world and
imposed on reality.
Symbolic interactionism:
…a theoretical perspective derived from pragmatism which assumes that people

construct selves, society, and reality through interaction. Because this perspective
focuses on dynamic relationship between meaning and actions, it addresses the
active processes through which people create and mediate meanings. Meanings
arise out of actions, and in turn influence actions. This perspective assumes that
individuals are active, creative, and reflective and that social life consists of
processes. (Charmaz, 2006, p. 189)
Theoretical perspective: The ‘philosophical stance informing the methodology and thus
providing a context for the process and grounding its logic and criteria’ (Crotty, 1998, p3).
Theoretical sampling:
A type of grounded theory sampling in which the researcher aims to develop the
properties of his or her developing categorise or theory, not to sample randomly
selected populations or to sample representative distributions of a particular
population. When engaging in theoretical sampling, the researcher seeks people,
223
events, or information to illuminate and define the boundaries and relevance of the
categories. Because the purpose of theoretical sampling is to sample to develop
the theoretical categories, conducting it can take the research across substantive
areas. (Charmaz, 2006, p. 189)
Transdisciplinary
A transdisciplinary team is characterized by integrated thinking based on the

sharing of knowledge and greater blurring of professional boundaries than in an
interdisciplinary team. Clinically, members are involved in role release rather than
role retention as they seek to develop a common knowledge base. Transition to
transdisciplinarity requires a shared theoretical base and common language among
members as a foundation for consensus building; clarity about targets for
intervention and means of measurement; breadth of appropriate interventions;
clearly understood program procedures and policies; and systematic observation
and feedback mechanisms to assist with team growth and quality assurance.
(Antoniadis and Videlock in Opie, 2000, p. 40)
Traumatic brain injury: An ‘injury resulting from trauma to the head and its direct
consequences including hypoxia, hypotension, intracranial haemorrhage and raised
intracranial pressure’ (Turner-Stokes et al., 2005, p. 2). Traumatic brain injury specifically
excludes pre- and peri-natal brain damage secondary to prenatal and birth-related events (New
Zealand Guidelines Group, 2006).
Usefulness: A criteria for against which a grounded theory study can be critically evaluated.
Usefulness related to the utility of the analysis arising from a study and its interpretations, its
applicability to further research, or other non-scientific contexts (Charmaz, 2006).
Work: A criteria for against which a grounded theory study can be critically evaluated.
Work relates to the explanatory power of a study; its ability to explain or predict observation
with respect to the theory (Lomborg & Kirkevold, 2003).
224
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Appendix 1: Key to transcription conventions
The transcripts for this study reflected as closely as possible the actual words and
speech patterns of the interview participants. Interview extracts have been edited to illustrate
points for the purposes of this paper, but all editing has occurred with the intent of retaining
the original meaning of the speech. Ellipses (…) have been used to indicate where speech
was omitted. Square brackets [ ] were used to insert editorial notes or words not present on
the audiotape. Rounded brackets ( ) were used to indicate where nonverbal sounds such as
laughter occurred on tape. Em dashes (–) were used in the place of hanging phrases resulting
in an incomplete sentence, interruption by another speaker, or where the speaker made a
meaningful pause.
235
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Goal planning in rehabilitation for people with acquired brain injury

Thesis · April 2008

Sexuality and COPD View project

The user has requested enhancement of the downloaded file.

A thesis submitted for the degree of

Date: 7 March 2008

Methodology: Constructivist grounded theory

As a physiotherapist working in both hospital and community-based rehabilitation for

1.2 Definitions of key concepts

1.2.1 Definitions of a ‘goal’

…the individually meaningful activities that a person cannot perform as a result of

1.2.2 Defining ‘goal setting’ and ‘goal planning’

‘Goal planning’ or ‘goal setting’ is an activity related to establishing or having ‘goals’.

Interestingly, in the field of psychology, definitions of goal setting do not always

1.2.3 Defining ‘rehabilitation’

The term ‘rehabilitation’ refers to a process aimed at enabling persons with

1.2.4 Defining ‘interdisciplinary team’

An interdisciplinary team is characterized by joint activity, collaboration, the

According to Opie (2000), interdisciplinary teamwork differs from multidisciplinary

1.2.5 Defining ‘acquired brain injury’

Finally, as mentioned above, the empirical research in this thesis centres on

hypoxia, hypotension, intracranial haemorrhage and raised intracranial pressure’ (Turner-

1.3 Research aims

2. To use grounded theory to explore how goal planning is applied in interdisciplinary

3. To examine how goal planning is conceptualised in the literature on clinical

1.4 Thesis structure

Chapter 4 introduces grounded theory – the methodology employed in the two

Chapter 5 presents a grounded theory investigation of how health professionals talk

FIGURE 1: Structure of the thesis

Chapter 2: Analysis of the Chapter 3: Systematic review of the

Chapter 4: Grounded theory

Chapter 5: Grounded theory

Chapter 6: Grounded theory

Chapter 7: Discussion and

Chapter 2: Variability in interpretation of goal planning and its

2.2 Origins and interpretations of goal planning in rehabilitation literature

• GAS (Kiresuk & Sherman, 1968),

Approaches to goal planning from industrial-organisational psychology, in particular Locke

While these different approaches to goal planning frequently include a number of

There is also considerable variation across recommended approaches to goal planning in

Relevant to the patient

Kiresuk & GAS Goal assigned with numerical values

Relevant to the patient

Bergquist & Not named Domains of goals not specified

Articles relevant to the following review were identified by conducting a literature

a) Improving rehabilitation outcomes (as determined by standardised outcome

b) Enhancing patient autonomy

d) Responding to contractual, legislative or professional requirements

Purpose Hypothesised Mechanisms Hypothesised Sub-mechanisms Examples

Purpose Hypothesised Mechanism Hypothesised Sub-mechanisms Examples

Purpose Hypothesised Mechanism Hypothesised Sub-mechanisms Examples

3. To evaluate i) That rehabilitation n/a Brown, Effgen, & Palisano,

ii) That rehabilitation n/a Trombly et al. (2002)

4. To meet That documenting goals Randell and McEwen (2000)

2.4.1 Goal planning to improve patient outcomes (as determined by standardised

2.4.1.1 Using goals to influence a patient’s level of conscious motivation

One core finding from the research in industrial-organisational psychology is that

2.4.1.2 Using goals to enhance the specificity of training effects

In an article on goal planning in physiotherapy, Randell and McEwen (2000) contended

2.4.1.3 Using goals for the purpose of a secondary therapeutic effect

2.4.1.4 Using goals to improve teamwork

Research into the effects of goal planning on rehabilitation teamwork is limited