What are the barriers and facilitators to goal-setting during rehabilitation for stroke and other acquired brain injuries? A systematic review and meta-synthesis

I bet the biggest barrier is your doctors and therapists not even suggesting getting to 100% recovery. Probably subtle and not so subtle ways of  limiting this so this failure to recover doesn't look so bad. Walking is the goal instead of running, skipping or hopping. 100 feet instead of two miles. Walking in the pool instead of swimming. I had a goal of reading a newspaper, my replacement OT changed that to reading a newspaper flat on the table with dycem. She could mark that as complete in one session but did absolutely fucking nothing about solving reading a newspaper with two hands held in front of you. That would have been incredibly difficult, stopping the spasticity of my arm muscles pulling downward, stopping the spasticity of my fingers and getting my fingers to extend to be able to release and grab a new page.  She did that because of the nonexistent stroke protocols to address these many upper limb problems I had and still have. Goal setting is incredibly simple: 100% recovery for all stroke survivors, you don't have to ask a single damned question.
http://cre.sagepub.com/content/30/9/921.full

1. Sarah E Plant1
2. Sarah F Tyson1⇑
3. Susan Kirk1
4. John Parsons2

1. ¹University of Manchester, UK
2. ²University of Auckland, New Zealand

1. Sarah F Tyson, School of nursing midwifery and social work, Jean McFarlane building, University of Manchester, Oxford Road, Manchester M13 9PL, UK. Email: sarah.tyson@manchester.ac.uk

 

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Abstract

Objective: To identify the barriers and facilitators to goal-setting during rehabilitation for stroke and other acquired brain injuries.

Data sources: AMED, Proquest, CINAHL and MEDLINE.

Review methods: Two reviewers independently screened, extracted data and assessed study quality using the Mixed Methods Appraisal Tool and undertook thematic content analysis for papers examining the barriers and facilitators to goal-setting during stroke/neurological rehabilitation (any design). Last searches were completed in May 2016.

Results: Nine qualitative papers were selected, involving 202 participants in total: 88 patients, 89 health care professionals and 25 relatives of participating patients. Main barriers were: Differences in staff and patients perspectives of goal-setting; patient-related barriers; staff-related barriers, and organisational level barriers. Main facilitators were: individually tailored goal-setting processes, strategies to promote communication and understanding, and strategies to avoid disappointment and unrealistic goals. In addition, patients’ and staff’s knowledge, experience, skill, and engagement with goal-setting could be either a barrier (if these aspects were absent) or a facilitator (if they were present).

Conclusion: The main barriers and facilitators to goal-setting during stroke rehabilitation have been identified. They suggest that current methods of goal-setting during inpatient/early stage stroke or neurological rehabilitation are not fit for purpose.

• Stroke
• rehabilitation
• goal setting
• barriers
• facilitators

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Introduction

Goal setting is a key part of stroke rehabilitation and is recommended in National Clinical Guidelines.^{1⇓⇓⇓–5} It is said to enhance patient confidence and motivation, engagement in, and satisfaction with rehabilitation, whilst improving task performance, team communication and team work and, possibly improving recovery, goal achievement and self-care.^6,7 This evidence has been summarised in two systematic reviews.^6,7 Rosewilliam et al.⁶ reviewed the effects of patient-centred goal-setting during stroke rehabilitation up to 2010, while Sugavanam et al.⁷ assessed the effects and experience of using goal-setting in stroke rehabilitation up to 2011. Both found that low methodological quality and heterogeneity of the selected studies meant that no firm conclusions regarding the effects of goal-setting could be drawn. Furthermore, both noted that adoption of patient-centred goal-setting was limited and faced multiple challenges, not least discrepancies between patients’ and staff’s perceptions and experience.

This is supported by work on staff’s perspectives of goal-setting.^{8⇓⇓⇓–12} Patient-centeredness is a central tenet of goal-setting. That is, patients should be actively involved in the process with clinicians who understand and respect their needs.¹³ However, the use of patient-centred goal setting appears to be a challenge. Both patients and clinicians often report difficulty with this approach, particularly during in-patient rehabilitation.^{6,9,11,12,14⇓⇓–17} Limited patient participation, professional skill and conflicting priorities are considered contributory factors to the difficulty using patient-centred goal-setting.¹¹ Several different methods of goal setting during stroke rehabilitation have been proposed^{2,6,7,17⇓⇓⇓–21} but no method of choice has emerged.^6,7,22,23

Thus as an initial stage to developing a goal-setting model which addresses the barriers to uptake during in-patient stroke rehabilitation, we undertook a mixed methods systematic review of contemporaneous evidence to specifically identify the barriers and facilitators to goal-setting during stroke rehabilitation using the ENTREQ guidelines for meta-synthesis.²⁴

^{More at link.}