Clinical Rehabilitation

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Goal setting in rehabilitation: an overview of what, why and how

Derick T Wade
Clin Rehabil 2009 23: 291
DOI: 10.1177/0269215509103551

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Clinical Rehabilitation 2009; 23: 291–295
Editorial
Goal setting in rehabilitation: an overview
of what, why and how
Setting goals with the patients and monitoring
their achievement is a core practice within much
rehabilitation, but the evidence base behind
this practice is patchy. This issue of Clinical
Rehabilitation has seven articles concerned with
various aspects of goal setting, and this Editorial
sets them in context. It considers the theoretical
basis underlying goal setting, especially in rehabi-
litation. It argues that a goal is the intended out-
come of a specific set of interventions. It suggests
setting goals has benefits beyond simply motivat-
ing the patient and team; it may coordinate activ-
ities and ensure that all necessary goals are
identified. It reviews whether goals should be
SMART (and what SMART means), and empha-
sizes that there may be a hierarchy of goals on two
axes (time, abstractness). It reviews the benefits
and problems of goal attainment scaling and,
finally, considers the ethical problems associated
with goal setting. It concludes that goals should
not necessarily be completely SMART, and that
goal attainment scaling may only be useful as a
measure in research. It emphasizes the need for
much more research into the cost-effectiveness of
this activity.
Introduction
Most human behaviour is goal-directed. In other
words, people generally act for a reason, however
nebulous or unconsidered that reason is.
Rehabilitation is ultimately concerned with changing
behaviours. One objective of rehabilitation is to
reduce ‘activity limitation’ (in the World Health
Organization’s (WHO) International Classification
of Functioning, Disability and Health (ICF) termi-
nology1); the goal is to increase a patient’s beha-
vioural repertoire as much as possible, within any
constraints imposed by disease and impairments.
ß SAGE Publication 2009
Los Angeles, London, New Delhi and Singapore
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Thus it should be no surprise that the identifi-
cation and setting of goals with patients in reha-
bilitation is a core component of the process,
much more so than in most other parts of health
care.
This issue of Clinical Rehabilitation includes
seven papers concerned with aspects of the goal-
setting process. This Editorial sets these papers in
the context of the whole process of goal setting.
It first considers what goals are, the reasons for
setting goals, and the theories that underlie goal
setting. Then it moves on to some practical issues
around setting particular goals and issues concern-
ing measurement of goal achievement. Finally it
draws attention to the resource implications of
goal setting and how this might influence clinical
practice.
Goals and goal setting
The Oxford English Dictionary defines a goal
as ‘The object to which effort or ambition is direc-
ted; the destination of a (more or less laborious)
journey. spec. in Psychol. An end or result towards
which behaviour is consciously or unconsciously
directed.’ It is important to note there are two
components to this definition: an end state and
an effort to reach that state.
Thus in the context of rehabilitation, goals have
two characteristics. First a goal is an intended
future state; this will usually involve a change
from the current situation although, in some
circumstances, maintenance of a current state in
the face of expected deterioration might be a
goal. Second, and of equal importance, a goal
refers to the intended consequence of actions
undertaken by the rehabilitation team. A goal is
not nor should be a simple prediction of what will
happen; it should be the intended result of some
intervention(s).
Goal setting, sometimes referred to as goal plan-
ning, is the formal process whereby a rehabilitation
10.1177/0269215509103551
292 Editorial
professional or team together with the patient
and/or their family negotiate goals. Although pro-
fessionals and teams will always have some reason
for their actions, the goals are often unstated and
unconsidered in the particular situation. In rehabi-
litation the goal-setting process ensures explicit
identification of the reasons for all activity.
Why set goals?
Why should the reasons behind rehabilitation
treatments be made explicit? The benefits of set-
ting goals in the management of organizations
have been investigated extensively2 and it has
been shown that setting a person goals increases
their behaviour change, presumably through
increasing motivation (the desire to act in a parti-
cular way). There is no particular reason to doubt
its effectiveness in patients participating in
rehabilitation.
However, it is far from certain that the time and
effort expended in a detailed and formal goal-set-
ting process is necessarily better than simply set-
ting a goal. Indeed one paper in this issue that
reports on a randomized controlled trial of three
approaches to goal setting specifically raises the
issue of whether a formal process is better than
simply using goal attainment scaling.3
Before dismissing the goal-setting process, it is
important to consider whether the process of
setting goals in rehabilitation has several other
purposes over and above motivating the patient.
The shared setting of explicit goals by a group
of people should ensure both that all actions
undertaken by each individual are contributing
towards the overall goal and that important,
necessary actions are not overlooked. Team
effort in setting goals should facilitate both the
efficiency (through cooperative activity) and the
effectiveness (through not omitting any important
actions) of rehabilitation.
Third, having a goal allows the effectiveness of
the rehabilitation process to be monitored. This is
particularly important because often it is unknown
which of several interventions might help (if any)
and it is important to stop ineffective actions as
soon as it is clear that they are not having the
desired effect so that an alternative way of
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achieving the overall goal can be started (if it
exists).
Lastly it has been suggested that the setting of
goals may help the patient in other ways. It may
reduce anxiety4 and it might increase insight into
and acceptance of limited recovery.5
Goal setting – theory
The setting and use of goals is a complex interven-
tion. There are many components, and the rela-
tionships both between the separate components
and between the process of goal setting and the
eventual outcomes are likely to be non-linear and
unpredictable. In this situation it is important to
use theory to guide all actions and decisions as far
as this is possible.6 In reality the relationship
between theory and practice is recursive: theory
will suggest or guide actions and research; and
the results of actions and research will confirm,
refute or alter the underlying theory.
The theoretical underpinning of goal setting in
rehabilitation has not been well researched, and
tends to depend upon theories used in other con-
texts.5 This issue has one paper7 reporting on a
systematic review of the theories that underlie
the practice of goal setting in rehabilitation, and
a second paper comparing the use of two different
theoretical approaches to setting goals.2 It seems
likely that different aspects of the process will
depend upon different theories, but at present
it seems likely that existing theories should be
reasonably applicable.
The goal-setting process
Whenever a patient’s problems are sufficiently
complex to require the involvement of a two or
more people from different professions and/or
the process is continued for more than a few
days, then a formal goal-setting process may be
needed to derive a set of goals that:
 motivate the patient;
 ensure that individual team members work
towards the same goals;

 ensure that important actions are not over-
looked; and
 allow monitoring of change to abort ineffective
activities quickly.
When only one person is involved with a patient
and the intervention is relatively brief and simple,
then a formal goal-setting process is less likely to
be needed. Nevertheless the considerations and
processes described below should be used, albeit
in an abbreviated way.
The first step is to establish what goals are
important to the patient, because goals are only
effective if they are considered desirable by the
subject. Establishing the patient’s goals is not
trivial and it is rarely wise to make assumptions
about the wishes and expectations of individual
patients in any situation, however obvious they
may appear. The process should also consider
the wishes and expectations of other important
parties such as the family, work colleagues, those
who are funding rehabilitation, and even the reha-
bilitation team itself.
At the same time the process needs to establish
what changes are at least possible and what
changes are not possible, and what would be
needed to achieve each goal and how likely the
change is. While this may be easy in some circum-
stances, it is often difficult, especially in complex
situations where a whole team is involved.
These preparatory stages are followed by a pro-
cess of sharing information and negotiating a set
of goals that between them acknowledge most or
all of the wishes of the patient and resolve as many
problems as possible. This is not to say that all of
the patient’s wishes are set as goals. It is to say that
some account is taken of their wishes, and some
response made.
In the process of goal setting it is important to
recognize that goals are hierarchical in at least two
ways. The first axis relates to time: there are long-
term goals (usually few in number), medium-term
and short-term goals. The second axis relates to
the conceptual level. One example is the hierarchy
of needs given by Maslow,8 who identified needs
as being physiological, safety, love/belonging,
esteem and self-actualization. An alternative
example is the WHO ICF model,1 where goals
might concern social participation, activities,
impairments or well-being.
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Editorial 293
It is also very important to link goals one to
another so that the patient can see the connection
between their own longer term aspirations and the
more immediate rehabilitation goals being sug-
gested. Further, if the process starts from a small
number of high-level goals it is more likely to iden-
tify most necessary actions and it may also encou-
rage interdisciplinary working with shared goals.9
Finally there is the process of documenting or
recording the goals set, so that progress can be
evaluated and so that all team members (including
the patient) know what is expected of them.
Setting a particular goal – being SMART
Most of the research into goal setting has focused
on the nature of a goal, and how manipulating
aspects of a particular goal may alter its effects.
This has led to guidance on setting the ideal goal,
and the acronym usually associated with this is
SMART. It is uncertain when this acronym was
first developed10 but the earliest known publication
is in 1981 when two articles in one journal men-
tioned the acronym, one in the title.11 More recently
the acronym SMARTER has also been used.
There is considerable variation, however, in the
actual words associated with each letter in both of
these acronyms. Table 1 shows at least some of
the words; these were derived from various web-
sites10,12–14 and other papers. Although at least
two of the words used are difficult to interpret
(‘magical’, ‘magnetic’), it is likely that the under-
lying concepts encompassed within the many
words used are important when setting goals.
Practical guidance on how to set SMART goals
is given in one paper in this issue.15
Although being SMART is often said to be
vital, it is worth quoting some sentences from
one of the earliest papers11 that referred to setting
goals in management. Doran wrote:
In certain situations it is not realistic to attempt
quantification particularly in staff middle-man-
agement positions. Practicing managers and
corporations can lose the benefit of a more
abstract objective in order to obtain quantifi-
cation. It is the combination of the objective
and its action plan that is really important
294 Editorial

Table 1 Some of the words associated with each letter of the acronyms SMART and SMARTER in the
context of goal setting

S Specific, significant, stretching, simple, stimulating, succinct, straight forward,

self owned, self managed, self controlled, strategic, sensible
M Measurable, meaningful, motivational, manageable, magical, magnetic,
maintainable, mapped to goals
A Agreed upon, attainable, achievable, acceptable, action-oriented, attributable,
actionable, appropriate, ambitious, aspirational, accepted/acceptable, aligned,
accountable, agreed, adapted, as-if-now
R Realistic, relevant, reasonable, rewarding, results-oriented, resources are adequate,
resourced, recorded, reviewable, robust, relevant to a mission
T Time-based, timely, tangible, trackable, tactical, traceable, toward what you want,
and many starting with ‘time-’ (e.g. -limited, -constrained, etc.)
E Ethical, exciting, enjoyable, extending, evaluated, engaging, energizing
R Recorded, reviewed, rewarded, realistic, relevant, resourced, research-based

And that with patients. It may well be useful as a sensitive

the suggested acronym doesn’t mean that every
objective written will have all five criteria.
If one of the originators of the acronym (who
used the word attributable for ‘A’) was flexible,
then perhaps modern practice should also be less
rigid in its adherence to being SMART.
and specific outcome measure17 in randomized,
controlled trials provided the goals are set by
people before allocation and are scored by people
unaware of group allocation. But I am much less
certain that it is useful as a routine measure of
outcome in daily clinical practice. What is clear is
that judgements about the success of rehabilitation
must not be based on goal attainment scaling as
it becomes demotivating2 and liable to gaming.

Goals and evaluation

One potential benefit of setting specific patient-
centred goals is that it might allow quantification
of outcome in each case, avoiding the need to use
the same single measure of outcome in all patients.
This approach is known as goal attainment scal-
ing, a technique for quantifying change in indivi-
dual patients first used in learning disability and
psychiatry16 but also used in rehabilitation.17
This issue has several papers that discuss or
investigate goal attainment scaling in rehabilita-
tion.3,18,19 Readers should note that there is
considerable debate about the actual scoring.
One paper18 puts forward the scoring system
(and also gives access to an Excel spreadsheet for
practical use), but the theoretical basis is chal-
lenged within the conference report5 and practical
problems are also discussed in other papers.15,19
My own conclusion based on one of the papers in
this issue3 and also on a systematic review20 is that
using the process of goal attainment scaling is prob-
ably useful in the clinical practice of setting goals
Goals and resources
Finally one paper21 raises another very important
issue that arises from some of the words in the
table (‘resources are adequate’ and ‘resourced’).
Specifically, Levack asks to what extent people
participating in the process of goal setting may
alter the goals they set, usually to a lower level,
because setting a higher goal may use more
resources than are considered reasonable.
He uses one approach to ethical problems –
utilitarianism – and he argues that in practice
using an utilitarian analysis could well justify set-
ting goals that consume more resources. Thus ethi-
cal organizations responsible for rehabilitation
should be pressing for adequate resources rather
than constraining the goals set. Unfortunately
political pressures usually favour almost any
other part of health care and the lack of strong
evidence to support his argument (which may well
be valid) means that we may remain underre-
sourced for a while longer.

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Conclusion
Goal setting is and will remain a central feature in
rehabilitation and is or should be a core compe-
tency of any member of a rehabilitation team.
However there are at least three major research
efforts needed. First, there should be a review and
synthesis for use in rehabilitation of the large body
of evidence concerning goal setting in all areas
including sports science and business management
as well as the smaller amount of evidence in reha-
bilitation. Second, studies in rehabilitation are
needed to confirm that the findings in other spheres
apply equally in health care. Specifically, do the
findings generalize to people with cognitive deficits
and psychiatric problems. Third, is the resource
used warranted by the benefits achieved (and
what are those benefits)?
In the meantime we should negotiate and set
goals with our patients that are not necessarily
completely SMART, and some goals may not be
SMART at all. Goal attainment scaling may be an
appropriate method to set goals, but will rarely be
a good measure of outcome except in double-blind
research protocols. And in complex cases we
should set goals in different timescales and
domains, and link them together.
Derick T Wade
Editor
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