What is a smart goal for COPD?

We set up a qualitative study to explore respiratory physiotherapists’ views of goals, and their experiences of goal-setting, with people with chronic obstructive pulmonary disease (COPD). We conducted face-to-face interviews with 17 physiotherapists, which were audio-recorded for subsequent transcription and detailed analysis. Most of the physios worked with patients with COPD in pulmonary rehabilitation (some combining this with acute care), or in community settings.

The full paper can be accessed here. These are the edited highlights.

Key messages

• Goal-setting in relation to COPD is challenging for respiratory physiotherapists.
• There is considerable uncertainty among physios as to how goal-setting should best be approached.
• Goal-setting can be driven by service needs, rather than patient needs. This creates tensions for clinicians who have a duty to fulfil both.
• Clinicians need time and resources to undertake meaningful goal-setting, and may need additional postgraduate training to help them resolve some of these issues.

Three main themes emerged from our data analysis:

• Theme 1: ‘Explaining goal-setting’ describes how goals were understood by physios, and their perceived purpose and value in respiratory rehabilitation.
• Theme 2: ‘Working with goals’ explores physios’ accounts of working with goals (or not), and the practicalities associated with collaborative goal-setting.
• Theme 3: ‘Influences on collaborative goal-setting’ highlights factors perceived by physios to be facilitating or hindering collaborative goal-setting.

Theme 1 – Explaining goal-setting

Definitions of goals  Goals were perceived as desirable achievements. Most stated goals should be personally meaningful to the individual patient, and identified from the outset. Aspects of the mnemonic SMART (Specific, Measurable, Achievable, Realistic and Timed) featured heavily. SMART goals were perceived as desirable properties of a goal, but could not always be attained:

‘I think “what am I trying to achieve with them?” I think that’s what a goal is. It’s what ultimately you’re trying to achieve. And the goal has to be something that’s relevant to the patient.’ (Emma, Band 7, Community)

Bernice associated goals specifically with aspirational undertakings (like mountain climbing):

‘Functional things, like walking or stair climbing, rather than their goal might be to climb Mount Everest er, do you know what I mean? I find it quite difficult really to put a goal to something that’s just a general practical improvement really’ (Bernice, Band 8, Acute and pulmonary rehabilitation)

And Lisa was unsure as to how to define goals:

‘I think if you think of a goal as something that facilitates behaviour change then that’s why it’s different from an outcome.  An outcome is the end result of doing your goals really, in a way.  Or using, I suppose a goal is working towards an outcome.  I’d.. yeah.. I think it’s really tricky I don’t think I really know.  I’m not sure it’s that clear’ (Lisa, Band 8, pulmonary rehabilitation)

Types of goals  These physios reported setting a variety of goals with patients, which could be considered as falling into one of four broad ‘types’; a) Aspirational, b) Functional, c) Condition understanding and d) Exercise related goals

Goal type	Description	Example quotation
Aspirational	The term ‘aspirational’ distinguishes between everyday pursuits and those which were considered more unusual or ‘important’ life goals. Sometimes these types of goals were considered possible. Other times this term was used to describe patient desires considered to be unrealistic or ‘non-goals’.	‘we had one man in the current group he said ‘I want to walk up [name of hill], which is one of the tall peaks. [..]  So we put him on the programme [..] and he actually managed to get up [name of hill] after.’ (Jackie, Band 7, pulmonary rehabilitation)  ‘sometimes you think you know that it’s unrealistic [..]  it’s a non-goal, like a new pair of lungs or I never want to be breathless again’ (Hazel, Band 7, pulmonary rehabilitation and Community)
Functional	Use of the term ‘function’ reflects its use in the physiotherapist interviews. Such goals had a direct and meaningful translation into the patient’s life, as opposed to those which purely related to exercise. It encompassed an array of pursuits from very mundane activities of daily living to the more unique.	‘We had one guy who turned around and said [laughs], he said there’s a pub at the top of [name of road] but it’s a huge hill to get there [..] it was important to him because his grandchildren liked going up there and, he was feeling he wasn’t being able to be a granddad properly because he couldn’t go out with them so much and we worked really hard with him and he managed to go and do these things’ (Penny, Band 7, pulmonary rehabilitation and Community)
Condition understanding	Goals to increase patients’ understanding of their own condition were widely discussed; patients were perceived to attend having received very little information about their condition and eager to know more.	‘They [patients] don’t know why they’re breathless, their G.P or whoever’s diagnosed them, practice nurses or consultants, never really explain to them in a huge amount of detail. […] So they’re very keen to learn, they’re very keen to find out more to be able to maintain their health for as long as possible’. (Richard, Band 6, pulmonary rehabilitation)
Exercise	Exercise goals were those which related to improving physical performance in a specific exercise or physical outcome such as an increase in walking distance, or lower BORG breathlessness scores.	‘I have target goals and actual goals on an exercise programme, on an exercise sheet. [rustles papers; gets sheet to show RS] So what we would do then if that person did actually achieve one and a half minutes, what he actually achieved the following week then I would give him a target of one minute 50 seconds, constantly progressing, yeah? So then you are moving on, the goals are continually changing.’ (Georgina, Band 6, pulmonary rehabilitation)

Purposes of goal-setting  There was a distinction made between patient-oriented goals (having direct relevance to patients’ concerns) and professional or service-oriented goals:

‘you do have your generalised goals of you know broad things like improving anticipatory care erm but I don’t think ….that’s something you want all COPD patients […] When I think of patient specific goals I think of what does this patient want to be able to do, go to the hairdresser, the pub, get to the bathroom you know, be able to have a shower, you know things like that. I think that’s different, it’s very individualised thing it’s very different for every patient’ (Emma, Band 7, Community)

Patient-oriented purposes included seeing goal-setting as:

• a means of giving patients hope: for example, hope that despite their difficulties with physical activity there was reason to continue‘It’s not pleasant to start exercising, for these patients, it’s not pleasant for anyone who’s unfit to get fit again, it’s even, you know, it, it’s much, much worse for them so they need to have that little bit of light at the end of the tunnel, something that they’re aiming for.’ (Hazel, Band 7, pulmonary rehabilitation and Community)
• a vehicle for enabling patients to return to valued activities and pursuits and so enhancing their quality of life
• a tool to enable clinicians to individualise rehabilitation ‘we’ll ask the patients “what are your main problems?” “what do you want us to do?” so we get an idea of what the patients actually, what the patient goals are and then tailor our treatment around what they actually want’ (Jackie, Band 7, pulmonary rehabilitation)
• a means of demonstrating progress to patients. The physios associated ‘functional’, ‘aspirational’ and ‘condition understanding’ goals strongly with patient-oriented purposes.

Profession or service-oriented purposes included: 

• To adhere to professional and service expectations. Goals are required within hospital documentation and by the Chartered Society of Physiotherapy (CSP), and goal-setting was emphasised during undergraduate training. But there was some uncertainty as to its usefulness

‘I guess it’s just that the CSP tell us that we’ve got to do this, that and the other and set patient-directed goals, […] And we haven’t really analysed whether it’s that important or not and it is difficult because we’re told to do this with everyone but we’ve not really looked at everyone to see if it’s important, with everyone’. (Oliver, Band 6, pulmonary rehabilitation)

• To demonstrate service effectiveness to commissioners, to secure continued investment in services. Goals linked to exercise were often associated with this purpose.

‘Most people make a significant improvement in sort of exercise tolerance and general well-being through the programme.  They’re sort of the goals we sort of look towards from a service point of view, functional ones are there more as an incentive.’ (Richard, Band 6, pulmonary rehabilitation)

One physio explicitly described ‘patient goals’ agreed during a goal-setting conversation as “incentives” to facilitate achievement of other goals that were aligned to demonstrating service effectiveness.  Some even questioned whether goal-setting was anything more than a “tick-box exercise” and felt there was a lack of evidence to support the usefulness of goal-setting.

‘You know I think some health care professionals think they’re a lot better than they are ‘coz they can tick a whole lot of boxes because they can achieve goals with patients. But you turn around and ask that patient what do they actually think of that healthcare professional, and they probably tell you a completely different story’ (Danielle, Band 7, Community)

Theme 2 – Working with goals

Only two physios reported not setting any goals with patients.

Setting goals  The process of goal-setting was often depicted as being a “negotiation”. But this idea of a negotiation was at odds with the realities of goal-setting as described by the physios. They said that while some patients arrived knowing what they wanted to achieve, this was not the norm, with most patients struggling to identify goals. Many physios described the process of collaboration within goal identification to be challenging, and this created tension between a desire for meaningful goal identification and the time available.

‘In our own practice we still believe that setting goals by yourself is not something you can just […]..they can’t do it for the first time, they don’t even know what pulmonary rehab is, they don’t know what they gonna achieve’.  (Clint, Band 7, pulmonary rehabilitation)

‘You know time constraints and assessments as well, you just really want to get this goal and they’re going “oh I don’t know really’ (Tammy, Band 6, pulmonary rehabilitation)

Goal specificity In those cases when patients did have goals, a lack of specificity was a frequent issue. Patients were said to have general, non-specific ideas relating to broad improvements, rather than precise SMART-amenable goals.

‘I think it has to be a specific thing, I think that’s one of our big problems when they’re trying to set goals is making them specific or specific enough to be able to measure whether someone’s done it.’ (Penny, Band 7, pulmonary rehabilitation and Community)

Another issue was the setting of ‘unrealistic’ goals. Some physios felt these could potentially demotivate patients and give them a negative experience of respiratory rehabilitation.

‘You know you’ve got to be realistic as well because […] if people don’t achieve stuff then they will actually become more disillusioned.  You want to give them wins, so they feel like, you know, they’ve actually done something good’ (Georgina, Band 6, pulmonary rehabilitation)

But other physios disagreed:

‘I don’t necessarily think it has to be realistic either […] I think sometimes you need to fail your goal to set realistic goals so I don’t think that, I think it’s wrong to give people false hope but I think if they have set an unrealistic target in their head unless they fail to achieve it then they’re not going to readjust, they’re not going to reset their goal because they’ve got something higher’ (Abbey, Band 7, Acute and pulmonary rehabilitation)

Reviewing goals There was no consensus on reviewing goals. Some physios reported reviewing goals throughout the rehabilitation programme, but some did it only at the end, some not at all, and some only reviewed specific types of goals.

‘once we’ve managed to get something down on paper, keeping them motivated to actually see through that goal, […] we used to kind of review it half way and review it at the end and now we kind of probably every week we do a little five minutes at the end of, how we going with our goals, we give them sheets to take home so it’s pinned up, we have a copy, they have a copy’  (Penny, Band 7, pulmonary rehabilitation and Community)

‘I must admit it’s not very formal our goal-setting and in the past certainly with [service name] it’s always been sort of at the back of their minds rather than the forefront.  Unfortunately, although we do identify [goals] there and then they’re generally not addressed throughout the programme. […]  I mean we do keep score sheets, its more objective […]  So obviously we’ve got good objective outcomes each time they come which we’re constantly reviewing.  But in terms of the more practical, functional goals they come up with themselves it’s not very well documented.’ (Richard, Band 6, pulmonary rehabilitation)

There was recognition that the patients’ and physios’ needs regarding goal setting reviews often differed.

‘Everything we do has to have a measurable difference, […] and I agree with that because I think that that’s absolutely important I  just don’t necessarily think that all the objective outcome measures that we use actually capture what we need to capture’ (Bernice, Band 8, Acute and pulmonary rehabilitation)

‘I find it really difficult to make goals SMART […] like getting them to even measure how far they can walk now versus what they’d like to be able to do because it’s like so abstract, isn’t it? […] (Nat, Band 7, pulmonary rehabilitation and Community)

Theme 3 – Influences on collaborative goal-setting

Individual Influences  

Patient: general health, comorbidities, awareness of COPD, understanding of pulmonary rehabilitation, desire for change.

Physio: attitudes to goal-setting; prior experience of goal-setting; training (undergraduate/ postgraduate).

‘Goal-setting is a nightmare. [laughs] That’s how I would describe it! With some people, not with all. I think if you goal-set with someone like me, it’s really easy because I’m goal-orientated […] and I set goals with people both in pulmonary rehab and like things like my staff and oh my God, for some people […] it’s like getting blood out of a stone’. (Nat, Band 7, pulmonary rehabilitation and Community)

 ‘I don’t do goals per se. I suppose I carry goals round in my head, but they’re probably more my goals for the patients rather than the patient orientated goals. Whereas I say, more junior staff tend then to write a problem list and a goal plan I would probably qualify that by saying maybe it’s just the difference in [..] university courses. You know, when I qualified 12 years ago, was that a priority? Whereas what’s being taught now, is more the goal perspective and the patient, you know, sort of collaborative working?’ (Kay, Band 8, Acute and pulmonary rehabilitation)

Those who remembered undergraduate training featuring goal-setting, recalled being introduced to SMART principles, the use of short and long term goals, and thinking about problem lists and goals. However, even those who did receive training at university, were uncertain how goal-setting should be implemented.

‘well we’ve talked quite a lot about this [goal-setting] over the last few months, within our team. Basically it’s difficult at the moment because I think all of us do things differently and I don’t know whether… no one really knows really whether they’re doing it right or wrong, or what’. (Oliver, Band 6, pulmonary rehabilitation)

Organisational Influences

Time pressure: Giving time to patients in consultations was considered a desirable and important thing. Time was needed for patients to consider and understand their condition, to think about their condition-related questions, and to explore how rehabilitation could influence their lives. But available time for new patient assessments varied across pulmonary rehabilitation programmes, from about 30 minutes to 1 hour.

‘I think goal setting is quite a time consuming, energy draining kind of task and I think that if no one else in the team can kind of do it, very well, or avoids it shall we say, then it’s quite a draining thing for you to have to do.’ (Nat, Band 7, pulmonary rehabilitation and Community)

‘I think it’s just the time thing again you’ve got to fit in the all your assessment, you’ve done the objective things, you spoke to them a lot during the subjective and then you start asking them about goals […] it opens up the floodgates sometimes doesn’t it?’ (Abbey, Band 7, Acute and pulmonary rehabilitation)

The physios working in the community felt less time limited than those working in pulmonary rehabilitation. However, in the community, caseload challenges were more influential; acutely unwell patients would take priority over more stable patients who were consequently left to pursue their goals alone.  The need to prioritise patients according to severity was perceived as more pronounced in the acute medical setting; with a heavy caseload of sick people to manage, time spent with any one individual patient was noted as brief.  In these areas, goal-setting was seen as less collaborative and more based around acute needs and discharge.

‘I mean I don’t know that many people still do goals on, on the wards. I think mainly on the wards it’s more this is acute admission we’ve got to get you better and well enough to go home and goals aren’t necessarily thought about’ (Penny, Band 7, pulmonary rehabilitation and Community)

Financial cuts had left multidisciplinary PR programmes marginalised by the loss of professional input. So some physios described having little access to, or input from, other disciplines and felt this affected the time available for goal-setting. Physios felt unable to include every recommended component, or to do everything that might be considered ‘ideal’; collaborative goal-setting was one such component.

‘So, things are getting done at probably 60%, coz there’s only me, rather than a team of four of us you know, everybody getting 100% of their job […] There’s only so much one person can do really.’ (Kay, Band 8, Acute and pulmonary rehabilitation)

‘I don’t have the luxury of time necessarily, so I’ll probably hone in on what I perceive as the important elements, so I don’t know whether I’m doing a, a, a token gesture at goal-setting to some extent. If, if it’s not simple to do, have I got the time to go back and revisit it on an individual basis with patients? Probably not’.  (Kay, Band 8, Acute and pulmonary rehabilitation)

Service needs  Rehabilitation services were seen as needing to justify their existence by providing evidence of short and long term improvements, not only to gain additional funding but just to maintain existing funding. Clinical outcomes demonstrating patient benefit were required by commissioners, and in this respect exercise goals could be seen as contributory. Service-oriented goals were often prioritised over more patient-oriented goals, which was challenging to the practice of collaborative goal-setting.

‘we use lots of outcomes, just as a service we’re always trying to prove that we’re worthwhile. That we’re worth spending all that money on, so we use lots of outcomes, and then a lot of the goals are built around those outcomes themselves’. (Richard, Band 6, pulmonary rehabilitation)

‘how much does pulmonary rehab cost? Well not a lot so the investment is probably worthwhile and if you can demonstrate that to the commissioners surely that’s of benefit.  So there are other benefits of looking at how you set your goals in a wider setting.’ (Steve, Band 8, Acute)

Approaches used by physios to assist with goal-setting

• Listening to the patient, to learn how their lives were affected by their condition and really mattered to them.

‘I think the process of getting in there, again, for me is to do with […] finding out what it is what  makes  that  patient  tick  so  what  it  is  that  is  high  on  their,   functionally  really  what  it  is  what  they  would  like  to  achieve’  (Danielle, Band 7, Community)

• Prompting patients to think about what they wanted to achieve initially, before following this up in the second or third week of rehabilitation to agree any goals.

‘So we kind of tell them to be thinking about goals on the first day as well, on the assessment day […] goal setting used to be the 3rd week, but now we’ve moved it to the 2nd week’ (Clint, Band 7, Pulmonary Rehabilitation)

• Using responses from a disease specific questionnaire, such as the Chronic Respiratory Questionnaire (CRQ) to help patients identify any things they could not do, but would like to.

‘If they can’t think of a goal, I then go on to say “well what are you having problems with?” if they can’t tell me then we get the CRQ out and say “well you’ve ticked that you can’t bend down and you’re struggling to get dressed, is that something you want to improve on?’ (Jackie, Band 7, Pulmonary Rehabilitation)

• Dealing with unrealistic goals. Unless the goal was something completely unobtainable (like wanting a new pair of lungs), most physios used the strategy of breaking large, potentially unrealistic, goals down into smaller ones, rather than not working towards their patients’ goals at all, in an effort to keep their patients’ experiences of respiratory rehabilitation positive.

Some physios had issues with using a problem-focused approach to collaborative goal-setting because a) a patient’s reported problems did not always equate to a desirable goal from the patient’s perspective, or b) patients might not perceive themselves to have any particular difficulty.  The latter may have been because any relinquished or reduced activities had been given up gradually (due to the gradual onset of their COPD), or because they did not perceive COPD to have significantly affected their lifestyle.

‘Sometimes it is really hard to find a goal for people.  I’ve had quite a few patients who I actually haven’t been able to set and usually no matter how, which way you ask them you know to get a goal they just can’t come up with anything  and then you feel like you’re telling them goals to achieve, because then you say “well, what about if you can walk to the shops without stopping?” and they’re like “ok” but it might not be important to them they might not care that they have to stop 5 times, they might be so used to doing that be now that it doesn’t make a difference?’ (Tammy, Band 6, pulmonary rehabilitation)

Conclusion

Goal-setting in relation to COPD has been found to be challenging for respiratory physiotherapists, with emphasis on the difficulty surrounding goal identification, and clinical practices vary. There is considerable uncertainty as to how goal-setting should be approached and there are times when goal-setting is driven by service need, rather than patient values. This creates tension for clinicians who have to fulfil both patient needs and service needs. In addition to being given the time and resources necessary to undertake goal-setting, clinicians may also need additional training to help them resolve some of these issues. This work highlights a need for wider discussion to clarify the purpose and implementation of goal-setting in respiratory rehabilitation.

“Giving hope, ticking boxes or securing services? A qualitative study of respiratory physiotherapists’ views on goal-setting with people with chronic obstructive pulmonary disease” Clinical Rehabilitation. 2016. Epub ahead of print

Authors: Summers RH, Ballinger C, Nikoletou D, Garrod R, Bruton A, Leontowitsch M.

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