The process of identifying goals among patients in skilled nursing facilities : a grounded theory investigation

Patient involvement in the goal setting process is important in occupational therapy in order to identify goals that are meaningful and purposeful to each patient. Occupational therapists also have an ethical responsibility to involve patients in the goal setting process. There are several assessments available, such as the Canadian Occupational Performance Measure and the SelfIdentified Goals Assessment (SIGA), to help patients address goals that are important to them. The purpose of the study was to investigate why some patients change their goals, and why others remain committed to their original goals. The study used the grounded theory qualitative approach. Data were collected on ten patients with neurological and orthopedic impairments in a Northwest Ohio skilled nursing facility. An occupational therapist administered the SIGA to newly admitted patients. The investigator then administered a semi-structured interview within 48-72 hours of SIGA completion. Data analysis included open coding to develop categories, axial coding to define causal conditions using the Conceptual Framework for Therapeutic Occupation, and selective coding for theoretical formation. No participants wished to change their self-identified goals. Influences on goal setting included family, the facility, future living possibilities, and especially the occupational therapist. SIGA goals were perceived as instrumental toward the ultimate purpose of returning home. The Process of Identifying Goals 3 The Process of Identifying Goals Among Patients in Skilled Nursing Facilities: A Grounded Theory Investigation Patient involvement in the goal-setting process is important in occupational therapy in order to identify goals that are meaningful and purposeful to each patient. According to the Occupational Therapy Code of Ethics (2000), “Occupational therapy practitioners shall collaborate with service recipients or their surrogate(s) in setting goals and priorities throughout the intervention process” (p. 614). In addition to the ethical rationale, there is a regulatory rationale. The Joint Commission on Accreditation of Healthcare Organizations requires active patient participation in goal setting and rehabilitation planning (1997). Gagne and Hoppes (2003) addressed the issue of patient involvement in occupational therapy goal setting. They used a quasi-experimental design to examine the effects of goal-focused therapy on patient performance in occupations of daily living. Patients (N=31) from a rehabilitation hospital were assigned to either the experimental or control group. Each patient was measured on the Functional Independence Measure (FIM) at admission and at a two-week follow up appointment. The experimental group had possibly greater mean gains on all self-care occupations; however, only upper-body dressing demonstrated statistical significance (Gagne & Hoppes, 2003). Although little research has addressed whether patient involvement in occupational therapy goal setting enhances outcomes, Pollock (1992) theorized that active client involvement in goal setting increases motivation to participate in the therapeutic process, thereby increasing the likelihood the client will be able to overcome difficult challenges in therapy. Nelson (1997) argued that patient involvement in goal setting is important and advocated research to attain a better understanding of this phenomenon. The Process of Identifying Goals 4 McAndrew, McDermott, Vitzakovitch, Warunek, and Holm (1999) used a 5-point Likert scale to study patient and occupational therapist perceptions of the collaborative goal setting process. They found that therapists tend to have positive feelings towards collaborative goal setting, while patients tend toward neutrality on this issue; however, these authors also found that patients experience positive feelings when therapists affirmed goals that were important to them (McAndrew et al., 1999). Patient involvement in goal setting has also been discussed in other health care professions. In nursing, a quasi-experimental study compared two methods of goal setting: mutual goal setting and nurse-determined goal setting. This study generated pilot data indicating that patients involved in mutual goal setting have better outcomes than patients involved in non-mutual goal setting (Czar, 1987). Several factors have been identified that might influence the goal setting process. The first is the quality of the therapeutic relationship (Lyons, 1994). Lyons emphasized the importance of establishing “a context for interaction that facilitates rather than inhibits clients’ full participation in any decision making” (p. 28). One way to do this is by establishing rapport with the patient without overwhelming the person with a series of personal questions. A second factor is patient motivation (Treishmann, 1990). Treishmann suggested that a passivity-reinforcing environment might cause a lack of patient motivation; therefore, modifying the environment to encourage patient selfdetermination may be a solution to this problem. The third factor is learned helplessness (Raps, Peterson, Jones, & Seligman, 1982). Learned helplessness may be one reason why some patients view therapists as all-knowing experts in goal setting and themselves as incapable of setting their own goals. The Process of Identifying Goals 5 The patient goal setting process was the focus of a single case qualitative research study. Barclay (2001) used in-depth interviews and patient observations to study the goal setting process between an occupational therapist and a patient with a spinal cord injury. This study determined that the patient goal setting process is influenced by the patient’s past experiences, his concept of independence, his understanding of goals, and use with a shared, understood language (Barclay, 2001). Northern, Rust, Nelson, and Watts (1995) used audiotapes of patient evaluations, occupational therapy interviews, and a patient participation evaluation form to examine whether or not occupational therapists involved clients and their families in the goal setting process. The study found that clients and their families are involved in the goal setting process; however, they are not certain of their precise roles in the process. Neistadt (1995) surveyed occupational therapists in an adult physical disability setting to determine the methods that they used when assessing their clients’ goals for therapy. The results indicated that although the therapists consistently note client’s priorities, they do so mainly through informal interviews. Although informal interviews are important for establishing rapport, Neistadt argued that formal procedures for assessing clients’ goals should be used to ensure that clients’ address goals that are truly important to them. The Canadian Occupational Performance Measure (Law et al., 1990) and the Self-Identified Goals Assessment (Melville, Baltic, Bettcher, & Nelson, 2002) are two standardized goal assessments used in occupational therapy. The Canadian Occupational Performance Measure (COPM) is an “individualized measure that is client-centered, generic (that is, not diagnosis specific), and crosses developmental stages” (Law, 1990, p. 34). It is a standardized assessment that consists of a five-step process based on a semi-structured interview. It allows patients to identify performance areas that are important to The Process of Identifying Goals 6 them and rate them on their importance, performance, and satisfaction. The COPM is designed to be used by most occupational therapists, except those who work in very specialized areas. The COPM has been tested for reliability and validity. Law and Stewart (1996) found that the COPM had good test-retest reliability for Performance and Satisfaction. Construct validity and criterion validity were evaluated using a multivariate analysis with the Satisfaction with Performance Scaled Questionnaire, the Reintegration to Normal Living Index, the Life Satisfaction Scale, and the Perceived Problem Check List. The results showed that the COPM is significantly related to these four measures (McColl, Paterson, Davies, Doubt, & Law, 2000). The Self Identified Goals Assessment (SIGA) was developed because United States subacute care settings require briefer assessments than the COPM. The SIGA is designed to be used by occupational therapists working in subacute rehabilitation and skilled nursing facilities. The SIGA is meant to “help the patient identify personally meaningful occupational goals to be addressed in therapy and to evaluate changing levels of patient-defined success in desired occupations” (Melville, Baltic, Bettcher, & Nelson, 2002, p. 650). The therapist interviews the patient to help the patient identify meaningful and purposeful areas that need improvement. Hodge (1999) used focus group interviews with occupational therapy clinicians who were using the SIGA to study the content validity of the SIGA. The results supported the content validity of the SIGA. Therapists found the SIGA to be clear and useful. Hodge also made suggestions for modifications to the SIGA. Cassidy (2000) used focus group interviews to study the clinical utility of the modified SIGA. The therapists felt that this assessment helped clients gain some control in their therapy and increased their participation and motivation (Cassidy, 2000). Overall, the therapists found the SIGA to be clinically useful. The Process of Identifying Goals 7 A study by Melville, Baltic, Bettcher, and Nelson (2002) investigated 30 patients’ perspectives of the SIGA using a four-step process. The process included structured interviews about the usefulness of post-admission and pre-discharge administration of the SIGA. The postadmission interview was given within 48 hours of an occupational therapist administering the SIGA. The results confirmed that 29 of the 30 subjects said that they recognized their own goals. Interestingly, Melville et al. fo