Setting goals to live well
PhD project funded by Strathcarron Hospice and
the University of Stirling
“You matter because you
are you. You matter to the
last moment of your life
and we will do what we
can not only to help you
die peacefully but to live
until you die”
(Dame Cicely Saunders)
Background
Palliative care: "a support system to help
patients live as actively as possible until death”
(WHO 2004).
Three phase research project
1. Structured literature review
2. Study of current goal setting practice in one
hospice setting
3. Development and evaluation of a research
based goal setting intervention
From the literature…..
• Goal setting is important but there is no clear
definition of what it means or which theories
underpin it;
• Professionals tend to focus on problems and
symptoms. Patients focus on what they want to
‘do’;
• There are particular challenges for healthcare
professionals because of the deteriorating and
unpredictable nature of patients’ health.
The Strathcarron research……
Goal setting happens within the hospice, but…….
• Professionals tend to focus on ‘important goals’;
• The process is implicit rather than explicit;
• Professionals tend to focus on their own areas
of expertise;
• Successful goal setting relies on collaborative
action planning between the patient and the
multidisciplinary team.
Co-production
• Developed G-AP PC from an existing framework
from stroke rehabilitation (G-AP)
• Based on 3 theories:
– Self efficacy
– Goal setting theory
– Health action process approach
• Identified additional theories relevant to
palliative care:
– Hope theory
– Affirming life; Preparing for death
Theories
Key constructs
Active ingredients
•
•
Efficacy beliefs
Outcome Expectancies
↑ motivation
Goal specificity
Goal difficulty
Feedback
↑ persistence + effort
(Latham & Locke)
•
•
•
Health action process
approach
•
•
Action Planning
Coping Planning
Intention-GAP–behaviour
SCT: Self Efficacy
(Bandura)
Goal setting theory
(Schwarzer)
Hope theory
(Snyder)
↑ resilience
↑ goal related performance
↑
Activate & maintain goal directed behaviour
•
•
Recognising one’s worth
Developing alternative goals or
pathways to achieve goals
Being listened to – identification of goals
which are important to the person - ↑
motivation and ↑ goal related behaviour for
all
Recognition that goals can be blocked and
that alternative pathways may need to be
identified and that the patient, the family
and professional may all have a role to play
Frameworks for coping
with living and dying
(Bye)
•
Affirming life; preparing for death
Supporting people to live actively while dying
Self
Efficacy
(Bandura)
Outcome
expectancies
Efficacy
beliefs
Increased
motivation
and
resilience
Goal setting
theory
(Latham & Locke)
Goal
difficulty
Goal
specificity
Feedback
↑ persistence
and effort
↑ goal
related
performance
Health action
process approach
(Schwarzer)
Intention
Action and
coping
plan
Behaviour
Hope theory
(Snyder)
Developing
alternative
pathways to
achieve
goals
Developing
alternative
goals
Recognising
one’s worth
(being listened
to)
Affirming life
Preparing for death
Pre- goal setting
phase:
Goal negotiation and goal
setting (a):
Sort out immediate
problems
Stage 2
Stage 1
‘What do you want to do in
the next wee while?
‘What’s really important to you just now?’
An opportunity to express what’s important in
life just now
Goal negotiation and goal
setting (b):
Agree on a meaningful
short term goal
Stage 5
Appraisal and feedback
‘How did you get on?’
Satisfactory
Progress:
•Celebrate
success
•Agree new
AP/CP
•Negotiate new
goall
Stage 4
Little or no
progress:
•Grieve failure
• Re-target
AP/CP
• Revise goal
• Goal
disengagement;
negotiate new
goal
Action/
Behaviour
“Carrying
out the
plan”
Exit G-AP PC
Stage 3
Action and coping plan:
‘What if’ plan
‘Who does what’ plan
Confidence rating
1. What’s important to you right now?
2. What do you want to do in the next wee while?
3. Action and coping plan:
(how confident do you feel about it?)
• ‘What if’ plan
•
‘Who does what’ plan
4. Carrying out the plan - provide support, as agreed
5. Appraisal and feedback:
How did you get on? – what went well, what didn’t go so
well?
How do you feel?
Is it still important to you?
What next?
Aims of the Pilot
• 1. How feasible is it to use G-AP PC in routine
care in one hospice setting?
• 2. How acceptable is G-AP PC to professionals
and patients as a method of eliciting goals?
• 3. Does staff goal setting practice alter
through use of G-AP PC?
G-AP PC Pilot
• Pilot use of G-AP PC with Yellow Team over
3 months
– Used with all patients –completion of questionnaire if not
used;
– Interviews with staff;
– Interviews with patients;
– Analysis of case notes.
Who took part?
• 24 members of staff
Qualified
nurse
9
Nursing
Auxiliary
4
AHP/comp Doctor
therapist
4
3
Social
worker/
Chaplain
4
Malignant disease
Non malignant
Discharged home
Discharged to
another care facility
Patient died
Patient still in
hospice at end of
pilot
Male (n = 34)
32
2
Female (n = 8)
5
3
16
1
3
0
16
1
4
1
Reasons for not having goals
(n = 12)
Male
Female
Patient on LCP
2
2
Patient had
cognitive/communication
impairment
3
0
Goal folder unaccounted for
4
0
Patient transferred from
another team
1
0
Findings
• Examples from case note analysis
• Patient’s comments
• Professional’s comments
What’s important to you just now?
‘Increasing mobility so I can get
in a bath and relax with a whisky’
What do you want to do in the next wee while?
To have a bath
What are the steps to achieving that?
‘To transfer from bed to chair, then bed to
bath.
Agree on the specific goal the patient wants to work on
My goal
How confident do you feel about managing this?
1
2
3
4
5
6
7
8
9
10
Not very ……………………………..Fairly………………………………………………Very
If confidence is below 7, discuss the things that might get in the way and ways around the
potential difficulties. Repeat the confidence rating once you have done this
What I need to do
‘improve strength to transfer’
What I need help with and
who I need to ask for help
‘nurses and physio to improve strength. Nurses to assist to
transfer and bathe.’
‘What if’ plan….
‘fatigue – resting as much as possible. Pain – Analgesia
before going for bath.’
(think of things that might
get in the way, and how they
might be overcome)
‘…he did transfer from his bed to the wheelchair in the afternoon as practice
for getting to the bath.’
‘Patient declined a bath this morning stating he was too tired but was keen
to pursue this tomorrow. He would like to stay in bed today to try and
conserve energy.
Two days later: ‘patient was too uncomfortable when he stood up to
transfer onto a chair for a bath, tried the shower chair, still uncomfortable,
agreed may benefit from pain relief prior to movement, but patient had the
whisky in bed.’
Next day: ‘pain relief given. Patient managed 6 steps and tolerated sitting in
shower chair. Enjoyed shower. Enjoyed his whisky after shower with lunch.
Next day: patient very poor today. Commenced on LCP.
What’s important to you just now?
‘getting out and about with family.’
What do you want to do in the next wee while?
‘go out with family, preferably away from the hospice.’
What are the steps to achieving that?
Steps: ‘planning time and day. Arranging with family.’
Agree on the specific goal the patient wants to work on
My goal
Go out for lunch with my family.
How confident do you feel about managing this?
1
2
3
4
5
6
7
8
9
Not very ……………………………..Fairly………………………………………………Very
If confidence is below 7, discuss the things that might get in the way and ways around the
potential difficulties. Repeat the confidence rating once you have done this
What I need to do
‘Arrange time with daughter to take me.’
What I need help with and
who I need to ask for help
Nurses – pain medication.’
‘What if’ plan….
‘not feeling great : weak – use wheelchair. Pain – take
medication’
(think of things that might
get in the way, and how they
might be overcome)
10
‘when discussing transport
options for hospital appointment
tomorrow, it was suggested that
patient’s daughter could take her.
Plan to take her to appointment
then out for lunch.’
Appraisal and feedback:
How did it go?
What went well?
What didn’t go so
well?
‘patient had a wonderful day and actually went shopping
as well as lunch which she hadn’t planned. She was
pleased she took pain relief and her wheelchair.’
Nothing.
How do you feel about ‘wonderful!’
it?
Is it still important
to you?
What next?
‘plans to go out again, hopefully this week.’
What patients said ….
it’s sort of motored me to
get up off my backside
and get going again……
What patients said ….
…..they know I want to get
back and see the dogs –
and walk the dogs
What staff said…
• Positive about use of G-AP PC – benefits for
staff as well as patients
• Confusion about all the questions in the paper
work – ‘what’s important’ and ‘next wee
while’ could be merged
• Frustration about where to keep the paper
work
• Not all staff engaged with the process
What staff said…
‘this gives you something
hard that you can really
focus on’
What staff said…
“And it just kind of changed how you
think about pain as well – so instead of
saying – well, tell me about your pain,
you’d say – well, what’s your pain
stopping you from doing at the moment,
and then that would become the focus
of setting a goal.”
What staff said…
‘I think maybe we work
harder to achieve it’
But…..
• Uptake was not consistent or
universal
• Success reliant on ‘key players’
• Not all goals were documented
• Predominantly led by nursing and
medical staff
‘These kinds of questions would
be in our assessment of a
patient and their family
anyway’
Next steps….
– Alterations made to G-AP PC
• Merging of ‘what’s important to you’ and ‘next wee
while’ question
• Changing confidence rating to ‘importance’
– Implementation of G-AP PC throughout the
hospice
• Rolling programme of training set up
• Champions on the ward
• Audit to monitor use of G-AP PC
What’s happening now?
• Goal setting now used throughout the
wards and soon to be extended to day
care and home care
• Supported by regular training, review and
goal setting champions
Finally……
References
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