Goal setting is like brushing your teeth……*

Goal setting is a funny old thing. It’s a bread and butter intervention for rehabilitation professionals (OTs, Physios, Dieticians, SALTs etc), and commonly used by groups of nurses, medics and psychologists too. Say ‘Goal Setting’ to these groups of people and they’ll nod in apparent understanding. Yet we know remarkably little about Goal Setting in practice**. And given its prevalence in healthcare that has huge patient and service implications.

Goal Setting is so commonly used it appears obvious. Our recent survey found that 98% of community rehabilitation services reported that they asked patients about their goal priorities http://www.ncbi.nlm.nih.gov/pubmed/25243765. You can understand why, therefore, that people sometimes question whether such an intuitively obviously and frequently used intervention should really be a priority for research. And yet it is precisely these issues that make it a burning topic…. because if Goal Setting is commonly used, I suggest it is almost as commonly misunderstood.

Goal setting, after all, is like cleaning your teeth. What? Bear with me. Did you clean your teeth today? “Of course”, you reply (if you didn’t go and do so now!). But precisely what do you mean when you say so certainly that you cleaned your teeth today? Did you use a tooth brush? “Yes, silly question”. And did you brush twice a day (or in the last 24 hrs) for at least 2 minutes, with the correct technique? “Hmmm”. And what about flossing, it’s shown to make tooth and gum hygiene much more effective. “Ehhhh”. And so it is with Goal Setting.

When we talk about Goal Setting, we are really describing a complex intervention with multiple components that requires considerable knowledge, skill, commitment, and aptitude to deliver (flexibly, but consistently) in practice. Given its prevalence and centrality to practice, it really is odd that people are (generally) not much more concerned about its everyday delivery, effectiveness and value. Perhaps, in part, it’s because it’s so like cleaning your teeth.

* A late night blog from Rio – inspired by a conference presentation by Prof. Jeffrey Braithwaite today and a Malcolm Gladwell anecdote.
** Though we do know a bit more now than a few years ago.

The relevance of research to practice

At a recent allied health professions (AHP) conference a bold statement was made by one of the speakers. It took, she said, 17 years for research to be integrated into practice. The implication was that research, though perhaps of value at some level, was of little to no use in answering the questions and challenges that face AHP clinicians today. As an applied healthcare researcher working to improve the quality and delivery of nurses, midwives and allied health professionals practice, this was a gauntlet that i felt could not go unchallenged. This blog is my response.

No reference was provided to support the 17 year ‘claim’, however a quick Google search found several papers that stated this was indeed the case. But there is more to this than meets the eye, and unpicking the research further sheds light on the validity or otherwise of this statistic for the conference participants.

There are various challenges in measuring the time lag between research and practice. It’s a complicated business. Where do you start measuring and at what point do you agree that the new research is embedded into practice for starters? Traditionally two stages are considered when looking at the translations of research into practice: from basic discovery to potential clinical ‘product’; and converting promising interventions into actual healthcare practice. Reading through the studies of research translation it is clear that the 17 year figure is a) an average that has been calculated with significant methodological challenges/limitations; and b) relates to the total time taken from basic scientific discovery to routine clinical implementation. And in this latter point lies the main issue with the 17 year figure for an AHP audience.

Allied health professions, together with our nursing and midwifery colleagues, are essentially applied healthcare practitioners. Sure there are times of basic scientific discovery, but by and large we are about taking knowledge and finding ways to maximise the lives of the people we work with. Research, unlike other approaches, gives us the confidence that these ways are evidence-based and likely to make a difference. In essence then AHP research is overwhelmingly focused on the second phase of knowledge translation: developing promising healthcare interventions into routine clinical practice. The trouble is there is precious little reliable evidence to inform us how long this phase of translation takes for research that is of relevance to AHP’S, and the methodological challenges for calculating this are considerable. What we can reasonably assume is that it need take nowhere near the 17 years it takes a basic scientific discovery to reach the same stage.

But why does this matter? Because, contrary to the impression that was made during the presentation, it is precisely through well conducted applied research that we can meaningfully answer the questions and challenges that AHP clinicians face today. And whilst we don’t know the time-lag to get such applied research into practice, it needn’t be lengthy: Physiotherapy self-referral is an excellent example.

Clearly we must strive to reduce the research into practice gap as much as possible. Working collaboratively with clinicians and patients at all stages of the research process, undertaking relevant research, developing usable evidence-based interventions, and reporting information that helps service managers decide whether or not to implement a new intervention or programme are all likely to be successful strategies in reducing this time-lag. But that will all be much harder to achieve if AHPs believe the message that research is of little to no use in providing contemporary answers to the questions and challenges that face AHPs and others today. It simply is not the case.

Sometimes all it would take is a little thought….

Miscarriage is one of those things that is so rarely spoken about that until it happens to you or your loved ones you don’t realise how frequent, and traumatic an occurance it is. Sadly, a friend’s girlfriend has recently suffered an early miscarriage. I can closely relate to what they’re going through: happily now the dad of 3 great kids, we’ve had three miscarriages over the years. It doesn’t matter how early it happens, or how reassuring the stats of future healthy pregnancies are – the loss in that moment and the pain you feel in days, weeks and months that follow is deep and real.

This evening my friend shared with me part of their healthcare experience in all this. My dismay at what he told me was magnified by the fact that we too had experienced exactly the same thing about 10 years ago. My friend’s girlfriend had to have a scan to confirm that their pregnancy was over, and a later one for medical reasons. To get the scans (which due to the early nature of the pregnancy is invasive, unpleasant and distressing enough as it is), my friend and his girlfriend – just like we had all those years before in a different Health Board – had to sit outside the ultrasound scan room and await their appointment together with a gaggle of excited pregnant couples, bumps and all, who were attending for their 20 week or so routine scan! Stop for a moment. Picture the scene. Imagine how that must feel. It’s not hard to realise how dreadful and unpatient-centred such an experience is.

You can see how it happens. Couples/ladies who have miscarried and therefore place an unscheduled and urgent pressure on the system vying for space with pregnant couples/ladies who have scheduled appointments for the scarce resource of an ultrasound scanner and sonographer …. But is it too much to ask that services give thought to the physical environment and the diverse needs of people who regularly require the same procedure? I’m sure there are examples of good practice out there, but the repetition of this awful experience ten years after ours, and in a different locale, makes me wonder how many other people go through the same thing elsewhere? Patient-centred care is a hugely challenging concept to define, never mind deliver. But sometimes all it would take is a little thought.

The Times They Are A-changin

There is no doubt, healthcare as we have known it in the UK is experiencing considerable stress and undergoing radical change. This is, predominantly, a response to the current economic crisis of the developed world, but government’s ‘soloutions’ to the crisis also have a substantial impact on how the resultant pressure on healthcare is ‘dealt’ with: for example whilst the NHS in Scotland has long been independent to its sister organisation in England and Wales, these services are now very different indeed.

Health services, including direct patient care services such as those provided by nurses, midwives and allied health professionals (NMAHPS) are left from this crisis with cash shortfalls and are under ever increasing pressure to reconfigure services differently, act smarter etc etc… The result of this is that clinical posts are often not being replaced after a member of staff leaves, and if they are are replaced are frequently downgraded so that a position previously taken by a person with an Agenda for Change (UK pay banding) Band 7, are often replaced at (a more junior and less experienced) Band 6 or 5. There have even been recent reports of letters offering voluntary redundancy letters sent to all Allied Health Professionals within one Health Board who were Band 7 or above; presumably with the intention of decreasing staff and replacing those posts they do keep at a lower grade. There is, it seems, a quiet, and perhaps inevitable slaughter, of the clinical skills base within healthcare.

Paradoxically, in parallel with these significant changes and pressures to the workforce, NMAHPs are expected to perform at a higher and more advanced level of clinical expertise – routinely incorporating complex decision making, outcome evaluation and person-centred care in their care and interventions. There is some evidence (for instance in routine outcome measurement ( see: http://www.biomedcentral.com/content/pdf/1472-6963-12-96.pdf) that some of these skills are best carried out by individuals with higher level qualifications and specialist experience – that is, higher graded staff; precisely of the type currently being culled within the NHS.

What then is the solution? Not all service reconfiguration is bad or unnecessary. In fact I’m pretty sure some of it is for the good, and perhaps only a significant event such as the economic downturn would create the circumstances required to enable a radical overhaul of services. But it’s not all good. And perhaps a radical overhaul of services in conjunction with increasing expectations of staff will only be realistically and effectively achieved if the profile of staff is radically re-thought as well- we are after all working with the same ‘type’ of professionals as existed in services as they were, whilst placing considerably different expectations upon them in reconfigured services.

Is now the time to consider making some NMAHP professions graduate entry degrees – with Masters entry qualifications like in other countries? And create a diploma type of qualification (akin to Enrolled Nurses of days gone by) which would be a generic health/rehabilitation qualification? The graduate entrants would be less in number and supervise the diploma staff who would deliver the bulk of care at less cost… Certainly it wouldn’t be a universal improvement or solution, but it appears a better solution than radically changing expectations without radically changing the staffing profile to best meet these new demands….

When Bob Dylan wrote The Times They Are A-changin in 1964 it was at a time of significant upheaval and uncertainty about the future. The song was a rally call to see the changes and take radical steps forward….perhaps now we need to be as radical in our thinking.