VOL: 98, ISSUE: 06, PAGE NO: 36
Jonathan Webster, MSc, BA, DPSN, RGN, is nurse consultant, care of the older person, Royal West Sussex NHS Trust, ChichesterClient-centred goal planning is becoming widely recognised as an effective component of the rehabilitation process (Davis and O'Connor, 1999). Goal planning is part of the overall care plan in which the client's own values, beliefs and aspirations are recognised and valued, and form the central focus of the rehabilitation process.
Client-centred goal planning is becoming widely recognised as an effective component of the rehabilitation process (Davis and O'Connor, 1999). Goal planning is part of the overall care plan in which the client's own values, beliefs and aspirations are recognised and valued, and form the central focus of the rehabilitation process.
People who require rehabilitation have potentially diverse physical and psychological needs, and their own goals should form the core of any rehabilitation programme. The process of client-centred goal planning encourages members of the multiprofessional team to work in partnership with the client, his or her family and each other, united by the aim of helping the client to achieve his or her desired outcome.
The purpose of goals
Goals enable clients, their carers or partners and the multidisciplinary team to focus on strengths rather than problems. They also enable the team to gauge where the client and family are in their 'thinking' (Davis and O'Connor, 1999). Once set, goals provide a central focus for all therapeutic activity, enabling clients to move away from a period of dependency to a level of achievement and/or adjustment to their situation.
Goals for rehabilitation can be divided into two groups: short-term and long-term (see Case study). Short-term goals can act as stepping stones to achieving longer-term targets. For example, a client may have the long-term goal of being able to groom herself, including cleaning her teeth, washing her face, combing her hair and applying her make-up on her own. A short-term goal for this client might be to be able to clean her teeth.
Through short-term goals the client and the multidisciplinary team can measure and chart progress, giving the client a sense of achievement. However, this requires regular review dates to accompany the goals in which the client, carer or partner and practitioner(s) are able to acknowledge any progress made. The activities prescribed to accompany the goals need to be meaningful to the client and not seen as frivolous, abstract or in isolation from day-to-day living (Webster, 2001). If they are not meaningful to the client, the question to ask is 'whose interests do they serve?'
Barriers to goal planning
The process of client-centred goal planning can be challenging. This is particularly true when practice is based on routine or when both clients and practitioners are expected to work within rigid boundaries.
In some cases the medical model can be seen as running counter to client-centred goal planning, as it focuses on the anatomical, physiological and biochemical causes of ill health (Aggleton and Chalmers, 1986) and not on needs as perceived by the client. This does not mean that the medical diagnosis should be discarded as irrelevant, but in the context of rehabilitation it should be seen as forming one part of many potential factors that influence the client in what he or she is able to do.
Empowering clients to identify meaningful goals can be daunting to the practitioner if the client appears passive or unwilling to participate, or if the goals are perceived as unrealistic, unattainable or counter to what the practitioner believes to be important. Clients should not feel pressurised into identifying and agreeing goals immediately. They must be given time to decide what they really want to achieve and what is meaningful to them.
When goals are seen as unrealistic, it is the nurse's role to be open, honest and supportive while helping clients to adjust to a new level of physical well-being. Practitioners should not collude or make clients feel that they have failed if a goal has not been achieved.
Rising to the challenges
Client-centred goal planning in rehabilitation is established in many areas. However, practitioners from multiprofessional teams face a variety of challenges in developing this approach, especially when it runs counter to either the organisation's or the discipline's philosophy and culture. Nurses need to welcome and embrace clients' right to decide what is important to them if client-centred goal planning is to be effective. Team working, in which the client and his or her family are central, must form the core of practice.
Practitioners who are new to goal planning also need to feel supported and should be given the opportunity to reflect, discuss, debate, question and learn. For client-centred goal planning to work, clients need to feel that they are listened to, that their views and beliefs are valued and appreciated and, most importantly, that they are central to all therapeutic activity.