Key messages

1. Goals should be developed in collaboration with, and agreed to by, the injured person.
2. Goals should be functional and SMART – specific, measurable, achievable, relevant and timed.
3. Progress towards goal achievement should be regularly assessed and goals reset or modified as necessary.

Setting goals

At the beginning of treatment, the healthcare professional should develop goals in collaboration with the injured person. The treatment selected to achieve the goals should also be determined in conjunction with the injured person. Current evidence suggests that where the injured person has a role in selecting treatment, better health outcomes are achieved.

Goals should focus on measurable improvements in function and participation at home, work and in the community. Goals should be SMART: specific, measurable, achievable, relevant and timed.

S	SPECIFIC	Names the particular variable of interest. For example, distance able to walk, hours at work on modified duties, social outings with friends.
M	MEASURABLE	Has a measurement unit (metres, hours, 0-10 scale).
A	ACHIEVABLE	Likely to be achieved given the diagnosis and prognosis for the person’s injury and any environmental constraints.
R	RELEVANT	Relevant or important to the injured person and other stakeholders.
T	TIMED	Timeframe within which the goal is expected to be achieved.

The effectiveness of treatment should be regularly assessed and progress toward goals recorded and communicated with the injured person. Treatment goals should be modified as they are achieved or if circumstances change, or significant barriers are identified. When measurable improvement is slow or absent, the cause/s should be identified and, where necessary, expectations in relation to recovery should be adjusted. It may be appropriate to reset goals, implement an alternative treatment plan, recommend the injured person be referred to another healthcare professional or service, or develop a discharge plan.

Healthcare professionals should actively support an integrated and collaborative approach which promotes common goals and communication about these goals between all parties.

Why are improvements in impairments not included in the goals?

Improvement in impairments, for example pain or depression scale scores, muscle strength and joint range of motion, may be measured as appropriate (see Principle 1). However, the ability to undertake everyday activities is influenced not only by impairments, but by environmental and personal factors. Goals that are focussed on function set a more meaningful and holistic target to work towards than goals focussed on impairments.

Examples of poorly constructed treatment goals	Examples of SMART goals
To return to work	To return to work in two days on modified duties with a lifting capacity of up to 5 kilograms.
To improve driving confidence	To be able to drive between home and work (15 kilometres) within three weeks.
To improve activities of daily living	Independently manage preparing breakfast three mornings per week within four months.
To reduce depression	To be able to concentrate on reading for 30 minutes four days per week within one month.

Return to work and goal setting

There is increasing evidence that work is generally good for an injured person’s health and wellbeing and that ‘long-term work absence, work disability and unemployment have a negative impact on health and wellbeing’. Healthcare professionals need to recognise the health benefits of work and support injured people to stay at work or return to work as soon as it is safe to do so. The evidence also supports the value of returning to, or staying at, work as part of a person’s rehabilitation and not just as the end point of rehabilitation.

Goals related to returning to work are therefore important to optimise an injured person’s health outcomes. These goals may be set in collaboration with the injured person, healthcare professional, employer, and other stakeholders as required. Goals may include increasing hours at work, changing duties at work, or attending team meetings or work functions. When returning to work is a long-term goal, healthcare professionals may also consider supporting injured people to participate in other activities outside of work to build their capacity in the short term. These activities could include increased household duties, scheduling more activities in the day, or volunteer work.

Not all goals have to be related to return to work. Return to work may not be a realistic goal or there may be insurmountable barriers to return to work. In these circumstances treatment is clinically justified when it promotes independence, improves function and participation, or demonstrably prevents the person from significantly deteriorating from their current level of function.

References

1. Australasian Faculty of Occupational and Environmental Medicine 2011, Position Statement: Realising the Health Benefits of Work, Australasian Faculty of Occupational & Environmental Medicine, Sydney, p. 22.

2. Henschke, N, et al 2008, ‘Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study’, British Medical Journal, vol 337, p. 171.