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RESEARCH REPORTS

A Structured Goal-Setting Process to Promote Functional and Measurable Outcomes in School-Based Physical Therapy: A Knowledge Translation Study

Ferro, Agnes McConlogue DPT, PCS; Quinn, Lori PT, EdD

Author Information
doi: 10.1097/PEP.0000000000000707

INTRODUCTION

Individuals with physical disabilities often require related services such as physical therapy (PT) to enable access to their school environments and curriculums. The Individuals with Disabilities Education Act (IDEA) mandates that goals be set to enable the child receiving services to be involved in, and make progress toward, the general education curriculum.1 Physical therapists are charged with annually setting goals on an Individualized Education Plan (IEP) meant to guide interventions and promote outcomes that optimize participation. Goals are required to be functional and measurable1 and exhibit a foundation in peer-reviewed research.2–4

The importance of goal setting is well documented across disciplines including rehabilitation focusing on physical, emotional, and behavioral services.2,4–9 Goals are optimal when they are specific, measurable, realistic, and relevant.4,6,8–11 Successful goal setting depends on the ability of health care professionals to create goals and interventions that address the individualized needs of the child.2 Furthermore, collaboration, in which children, families, and multidisciplinary team members are involved in developing realistic and specific goals, is an important component of effective goal setting.12–14 Collaboration with the child's multidisciplinary team allows for a shared approach to targeting skills within the context of routine.

Goal setting for a child in the school system presents some unique challenges: goals need to be applicable to the school setting and focused on relevant participation. While goal setting for school-based related services is mandated by IDEA, therapists may receive little training to create effective goals that are collaborative, specific, relevant, within context, and measurable.11 Research suggests that effective goal setting may in fact improve outcomes2,5; however, this is an area of limited research in the school setting.

A US Department of Education–funded study, PT COUNTS, explored the relationship between treatment intervention and outcomes for school-based PT.15 The authors used Goal Attainment Scaling (GAS) and School Function Assessment (SFA) to monitor progress of PT goal achievement. Goal Attainment Scaling is a valid and criterion-referenced tool to assess goal achievement.6 The SFA is a multidisciplinary assessment that encompasses level of assistance and supports during a child's typical daily routine.16 The results indicate that the GAS and the SFA may be useful tools for identifying/monitoring targeted skills and setting goals within the context of a school-based routine.15,16 School-based physical therapists may not have the opportunity to observe the child throughout the school-based routine, requiring input from the multidisciplinary team on performance or areas of need.

The ability to identify areas of need, within context throughout the school day, is an important component of goal setting. Löwing et al7 addressed this by comparing goal-directed therapy versus activity-focused therapies for 44 preschool children diagnosed with cerebral palsy. The authors completed an extensive goal-setting process for those receiving the goal-directed therapy approach, allowing team members to identify specific goal areas. Based upon the prioritized goal list, baseline measurements were obtained within the child's natural environment and routine. Therapy was implemented within context of daily routine and goals were shared to afford the child ample opportunities to practice. The authors report that 85% of the goals were met at expected or higher levels within the goal-directed therapy group whereas none within the activity-focused therapies group met that criteria.7

Despite being mandated by IDEA, previous research found that school-based therapists have not been able to consistently create goals that are functional and measurable.10 Goals were categorized according to the components of the International Classification of Functioning, Disability and Health model and measurement criteria were evaluated. Results founds that the majority of goals were not specific to the school setting, did not use objective measurement criteria, and often focused on remediating impairments. These findings indicate a clear need to assist therapists with creating goals according to best practice standards and prompted the authors of this study to develop a method to facilitate optimal goal setting in the school setting.

The present knowledge translation study set out to facilitate best practice standards in goal writing in the school-based setting. The aims of this study were (1) to evaluate implementation of a structured goal-setting method for school-based physical therapists, (2) to evaluate changes in school-based physical therapists' abilities to write goals aligned with best practice after training on a structured goal-setting method, and (3) to evaluate participants' perceptions while using a structured goal-setting method.

METHODS

Participants

Physical therapists were recruited via flyer/registration form posted to social media postings, Web sites, and announcements at pediatric school-based consortiums/school districts/agencies in Nassau and Suffolk counties in New York from August 2016 through January 2017. The inclusion criteria were a minimum of 1-year school-based PT experience and currently providing services in a school-based environment. Twenty-four school-based physical therapists registered for the 1-day training; 2 did not attend and 22 signed informed consent and participated. Participants represented a total of 7 counties in New York including a range of urban to suburban areas. The number of years' experience as pediatric therapists in a school setting was 1 year (n = 1), 1 to 5 years (n = 3), 5 to 10 years (n = 5), 10 to 15 years (n = 5), and more than 15 years (n = 8).

This study was approved by the Institutional Review Boards at Stony Brook University and Teachers College, Columbia University. All participating therapists signed informed consent.

Study Design

This study was framed around the Knowledge to Action framework,17 which included a 1-day training and follow-up mentorship. To assess knowledge translation, goals were evaluated pre- and posttraining and aligned with the end of the school year. Our structured and comprehensive approach guided therapists to create collaborative, relevant, measurable goals within the context of the school environment. This method served a dual purpose: training on the process of effective school-based goal setting and a self-guided goal analysis tool to ensure that goals meet best practice standards. Pre- and posttraining questionnaires were used to assess barriers and facilitators to implementation.

Training

Training program: Therapists were required to take part in a training program consisting of a 1-day training course and individualized mentored support via resources and phone consultation. The 1-day training was developed and presented by the coauthors and upon completion of the training, the participants received .7 continuing education units.

The training course focused on the importance of goal setting, key aspects of evidence-based goal setting, strategies for collaborative goal setting, and instruction for using the IDEA to GOALS method (see Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A289). The importance of standardized outcomes for diverse populations was also addressed and included the use of GAS and SFA. After completion of the course, the authors provided resources from the training including presentation documents, references on goal writing, and normative/baseline values. Therapists were also offered up to 2 phone consultations on the IDEA to GOALS method and integration of course content within their clinical practice. The authors followed up with each participant via phone and e-mail to set up convenient times to discuss experiences, questions, and clarification required for using the IDEA to GOALS checklist. Consultations were intended to align with quarterly reporting of progress on the IEP goals.

IDEA to GOALS method: The IDEA to GOALS method begins with a guided procedure to obtain information specific to the child and his or her routine, optimally completed as part of the child's evaluation/assessment. This process provides the therapist with a collaborative approach to goal identification by incorporating team members to identify skill-based needs within specific contexts. The therapists are guided to identify specific barriers to performance of targeted skills during the child's daily routine. The therapists are asked to obtain baseline measurement of the skill within context, identify involved team members, and determine objective means of assessment.

The GOALS (Generate, Observe, Align, Link, Set) checklist (see Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A289) was introduced as a self-guided process for therapists to aid in effective goal setting. The GOALS checklist itemizes components considered crucial to optimal goal development, specifically that goals should (1) be set in collaboration with input from team members, including the child whenever possible; (2) define the targeted skill and context(s) in which it will occur; (3) include sufficient and objective measurement criteria, and (4) be relevant and realistic for the child's individual school-based routine.

Outcomes

Structured questionnaires: Therapists' perceptions regarding goal setting were evaluated with structured questionnaires pretraining (prior to each of the conference dates: September, November, and January) and posttraining (June 2017). The questionnaires were developed to target components of goal setting considered evidence-based through current literature, information gleaned from analysis of pilot data, and the need to consider the therapists' unique perspectives. The questionnaires were designed with both forced choice (Likert scale) and open-ended questions to provide insight to therapists' perspectives regarding goal setting within the school setting. The conceptual framework was to reveal barriers and facilitators underpinning implementation of the IDEA to GOALS process for collaborative goal setting in school-based populations (questionnaire available upon request from authors). Presurvey questionnaires included demographic information including number of years practicing within a school setting, training on school-based goal setting, time spent creating goals for 1 child, and use of computerized programs/“goal banks.” We also asked therapists about relative importance of certain variables when creating school-based goals; this question was repeated pre- and posttraining for comparison. Variables included input from additional team members, knowledge of the child's routine, ability to assess targeted skill within the routine, use of normative data/baseline measurements, assessment of “body functions/structures” (eg, strength, range of motion), and results from standardized outcome measures. Postsurvey questions sought to identify perceptions specific to the 1-day training (expectations, effectiveness, and change in perception); use of the checklist (including collaboration with other team members, age range, and number of children); and impression of the overall process and effect on their treatment approach.

Evaluation of goals: Therapists provided representative goals for evaluation of interrater reliability of a grading rubric and to evaluate pre- and posttraining goals. Posttraining goals were not required to align with the same child/set of goals that were provided pretraining. This was driven by the intent to observe potential changes in therapists' goal setting versus goal progression for a specific child. All goals were deidentified.

The grading rubric was developed after an iterative process involving 5 therapists who rated the goals using a preliminary version of the rubric (Figure). Goals were randomly assigned and blinded to the raters, who had a range of 10 to 25 years of experience as school-based physical therapists (mean [SD]: 16.8 [2.0] years). Following discussions regarding inconsistent scoring and ambiguity surrounding the specific criteria for identification of team members and the parameters for “within context” and objective measurement, the rubric was revised and all goals were reevaluated by 4 raters using the current version (Figure). Each goal was blinded and randomly assigned to 2 raters. The raters were provided with written and verbal instructions on using the grading rubric. To use goal scores for comparison pre- and posttraining, the authors used one set of goal scores as the final score. For initial ratings that had greater than a 2-point difference between the raters, the 2 authors reviewed the ratings and resolved conflicts through discussion.

Fig.
Fig.:
This figure has 3 sample goals and their corresponding rating using the rubric. Goal 1 provides an example of a goal for a child who has high-level functional skills and is addressing transitions within the school setting. Goal 2 provides an example of a goal for a child who has lower-level functional skills and is addressing participation in the classroom. Goal 3 provides an example of a child with more complex impairments. Suggestions are provided for goals 2 and 3 to align with components of best practice.

Data Analysis

Quantitative analyses were conducted using SPSS Version 23.

Survey: Results were compared pre and post training using descriptive statistics. Frequency and percentage response distributions were reported, in addition to mean (SD) and ranges, for each survey item.

Reliability: Inter-rater reliability between therapists using the rubric was evaluated using an intraclass correlation coefficient (2.2).18

Pre- and postgoal comparison: Average scores from the IDEA to GOALS rubric for each therapist (3 goals per therapist) were calculated pre- and posttraining. Data were found to be normally distributed using the Kolmogorov-Smirnov test of normality (P > .05). Differences in goal rating scores pre- and posttraining were therefore evaluated using a paired samples t test. Significance value was set at .05.

Analysis of open-ended questions: To assess therapists' perceptions about goal setting and barriers and facilitators to implementation of the IDEA to GOALS method, we conducted a thematic analysis of the open-ended questions from the structured survey questionnaires using NVivo version 12. An inductive coding approach was used to analyze the responses to the open-ended questions.19 The coding frame was developed after multiple analyses of the data by 2 coders, independent of each other. For clarity and to ensure coverage but not repetition of data points, a review of codes/themes was completed with a third reviewer. All codes were saved within the NVivo database as nodes. As a result of highlighting areas that were unclear and doing further coding and refinement, the initial nodes were reordered, duplicated, or merged.

RESULTS

Reliability of IDEA to GOALS Grading Rubric

Three goals per therapist were evaluated using a rubric (Figure) pre- and posttraining, with the exception of 3 therapists who submitted only 1 to 2 goals for posttraining. The intraclass correlation coefficient (2.2) of the goal scores (n = 127) comparing 2 raters was 0.782 (95% confidence interval, 0.704-0.842), suggesting good reliability.18 Eighty-seven percent of goals were scored within a 2-point difference between the raters.

Presurvey Results

All participants (n = 22) returned the pretraining survey. Two therapists (9%) reported not receiving training in writing school-based goals, 7 participants (32%) reported no additional training outside entry-level education, and 13 participants (59%) reported receiving formalized instruction either through a conference or their employer. In addition to formalized instruction, 9 participants identified informal instruction through self-directed education via textbooks or American Physical Therapy Association (APTA) Academy of Pediatrics Web site. Eleven participants (50%) reported that they were unsure about current best practice evidence for school-based goal setting.

Therapists spent a mean of 12 minutes, range of 5 to greater than 15 minutes, completing IEP goal(s) for 1 child. Eight therapists (36%) estimated spending 5 to 10 minutes per child; 7 therapists (32%) estimated 10 to 15 minutes; and 7 therapists (32%) estimated greater than 15 minutes. With respect to use of goal banks, 9 therapists (41%) reported that all goals were computerized, 8 therapists (36%) selected that 25% to 75% of their goals were computerized, and 4 (18%) reported no computerized use (1 therapist did not respond to this question). Twelve therapists (54%) stated that the reason for using computerized goals was school/district requirement.

Therapists reported the following aspects as being either extremely important or important using a Likert scale (1= not at all important, 5 = extremely important) when creating goals: (1) input from child/teacher/family (n = 21), (2) knowledge of environment and daily expectations (n = 22), (3) assessment of child's ability to perform identified goal during evaluation (n = 21); (4) ability to assess identified goal within context or daily routine (n = 21), (5) ability to assess body structures and functions (n = 19), and (6) obtaining baseline measurements of skill performance (n = 22). Of less importance to respondents were (1) use of normative data when creating measurement parameters (n = 11), and (2) completing standardized outcome measures annually to assist with goal identification (n = 10). These values did not significantly change between pre- and posttraining (P > .05 for all comparisons).

Thematic analysis was conducted for the open-ended questions on the pretraining survey, which asked for therapists' perceptions regarding school-based goal writing. One theme that emerged was the importance of function and individualization when creating school-based goals. Therapists felt that the needs of the students should drive the goal, and that functional goal writing was an important component of creating an individual program, which is in line with current best practice. Therapists identified several barriers to writing effective goals in the school setting, including district requirements to use computerized goal banks without customization (10/13, 77%). This was often perceived as conflicting with the importance of setting individualized goals. In addition, therapists perceived that policy and professional restrictions (eg, adhering to school-based vs medical model for medically complex children) were a barrier to the implementation of optimal goal setting.

Posttraining Survey Results

Twenty-one participants completed the posttraining survey. All participants (n = 21, 100%) either agreed or strongly agreed that the training met expectations and instructors were effective and knowledgeable regarding goal setting. Nineteen participants (90%) strongly agreed or agreed that the training helped change their perspectives about goal setting in the school environment. Nineteen participants (90%) felt that communication with instructors, after the 1-day training, was helpful in facilitating integration of the goal-setting concepts into their clinical practice.

We conducted a thematic analysis of open-ended responses in the postsurvey questionnaire to obtain their perceptions on the IDEA to GOALS process. Four themes were identified, including facilitators and barriers to goal setting: collaboration with team members, effect on treatment, effect of district/administration requirements, and time constraints (Table). The majority of respondents found the IDEA to GOALS process useful when creating school-based goals. Collaboration with team members was viewed as a facilitator to support goal achievement; however, several therapists suggested that time constraints limited opportunity for collaboration. Most therapists felt that the IDEA to GOALS process had an effect on treatment in helping to focus interventions on functional aspects. District/administration requirements and time constraints were identified as barriers to goal setting, collaboration, and documentation. Similar to the pretraining results, district guidelines for goal setting, which including use of computerized goal banks and restrictions on collaborative goals, limited the ability of therapists to fully implement the IDEA to GOALS process.

TABLE - Four Key Themes and Respective Illustrative Quotes Provided by Therapists From the Open-Ended Postsurvey Questions
Theme 1: Collaboration with team members
“I had the opportunity to collaborate with another therapist who is also using the checklist. We both found it challenging as it really is a change in professional mindset. I have moderately changed my goal writing this year, but plan to expand it to how I create and generate my goals for my caseloads in the future.”
“I have been able to share what I've learned with a lot of coworkers since taking the course. It has helped many of us make more realistic and functional goals ... by having more open discussions.”
“The team approach enables us all to learn from each other, and see a much more total picture of the child. Consistency across disciplines improves child progress.”
Theme 2: Impact on treatment
“I believe that using this checklist would help assure goals are truly relevant to the student and team.” “The checklist reinforced and reminded me of the importance of function and carryover.”
“Working towards more functional and realistic goals has made me alter how I go into some of my treatment sessions. My treatments are more functional and I feel more comfortable relying on my team members to help me with data collection, measurements, etc.”
Theme 3: Impact of district/administration requirements
“We use (a goal bank) in my district, however I feel the goals are vague and not realistic to measurement in a therapy session.”
“My district is very specific regarding the writing of goals so I am limited in writing about functionality.”
“When writing the IEP goals the TM and coordinators request goals that only include what can be measured in PT sessions.”
Theme 4: Time constraints
“It has taken a little longer to utilize than I wanted therefore I was unable to complete it for all the children, however I think it can be extremely useful tool when appropriate.” “Being in many different districts and schools, time limits how much communication can be put forth into creating a cohesive and/or collaborative goal.”
“The process might be tedious in the beginning but I think with practice it will become easier.”
“It was a challenge for me to change the way I thought about goal writing and service implementation. It was a struggle to change my mindset, but once I got going it became easier.”
“IDEA to GOALS gave me a sense of direction especially for low functioning kids and kids with complex medical history. My treatment is very much directed to function instead of towards developmental approach.”
“I definitely keep the original goal more in the forefront of my mind and make sure my sessions are working on things that work toward that goal.”
“It has helped me to better identify the areas of focus for achieving the goals that I have written. I also love all of the standardized outcome measures that were shared and have been able to incorporate them into my reports.”

Comparison of Goals Pre- and Posttraining

Therapists were offered up to 2 follow-up phone consultations between pre- and posttraining assessments. Ten participants chose 2 calls, 10 chose 1 call, and 2 did not choose to schedule a phone consultation. Phone consultations lasted on average 16.4 minutes (range: 6-40 minutes).

To assess differences in goal writing pre- and posttraining, the mean goal score for each participant was compared. Mean (SD) posttest goal scores (5.81 [1.79]) were significantly higher than pretest goal scores (3.91 [1.47]) (t = 4.65, P < .001); mean difference: 1.90, 95% confidence interval of difference: 1.05-2.75; Cohen effect size: 1.04 indicating large effect size). With regard to time spent completing goals, 17 of 21 (81%) participants reported same/similar amount of time completing IEP goals pre- versus posttraining. The Figure has 3 examples of goals that were scored using the grading rubric.

DISCUSSION

This knowledge translation study was designed to evaluate implementation of a structured goal-setting method for school-based physical therapists. We found that this method was feasible to implement and reported to be beneficial by school-based therapists. We further identified participants' perceptions of facilitators and barriers to implementation of effective goal setting within the school setting. There was a statistically significant improvement in therapists' ability to write goals aligned with best practice (functional, measurable, and context specific) comparing pre- with posttraining.

While goal setting was identified as important by the therapists in our study, therapists were not consistently writing goals that were specific to the individual child, within their school routine, functional and measurable. Participants also reported lack of training for school-based goal setting. There is growing research in rehabilitation that goal setting is an important driver for successful outcomes3; however, the ability to construct appropriate goals may not be transferred to clinical practice.10 In this study, the average pretraining score was 3.91 and posttraining score was 5.81 out of a possible score of 9. This suggests that while therapists were able to improve goal writing with training, there is a continued need for improvement. Therapists in this study reported having difficulty including specific measurement criteria and setting goals that were relevant and specific to the school setting, despite having reported that these aspects were important when writing goals. This suggests that they had difficulty with knowledge translation into clinical practice.

The IDEA to GOALS checklist was created to provide a resource for developing and evaluating goals in clinical settings. Therapists in this study felt that the checklist and structured process were helpful and importantly did not increase the time spent by most therapists when creating IEP goals. The scoring rubric was created to evaluate the key aspects of goals and demonstrated good interrater reliability. There were, however, some discrepancies between raters using the rubric, which could be a result of experience disparity among raters as well as perceptions about context and measurement criteria. There was no clear pattern in these discrepancies and most differences were within 1 to 2 points. We recommend that the rubric undergo further validation but believe that it has usefulness as a tool to evaluate goals in clinical practice.

Therapists seemed to place less importance on the use of normative data and standardized outcomes when setting goals than might be expected from current best practice. The availability of normative data, such as time to complete stair climbing, normative walking speeds, and floor-to-stand times, can be an important foundation for goals that are grounded in context and function.20 Furthermore, results from PT COUNTS and other studies framed around goal setting and outcomes within the school setting suggest that use of normative data and GAS can facilitate effective goal setting.5,16

Participants highlighted that the 1-day training, resources, and follow-up phone calls were the most beneficial aspects of this study. The opportunity for mentorship after the 1-day training, as therapists were applying the IDEA to GOALS method in their respective sites, was found to be particularly beneficial as reported in the postsurvey questionnaires. As therapists reflected on the implementation of this approach in their clinical settings, most therapists felt that team members were open to collaboration and that it afforded greater opportunity for carryover throughout the school day. The barriers to collaboration were identified as lack of time to fully analyze each goal with the checklist and district/administrative restrictions. This was particularly evident in those participants who reported using computerized goals (N = 13). Therapists reported that this process could impact creativity in writing individualized goals. Such programs use pull-down menus with fixed response options. While this may improve efficiency of goal writing, such programs may indeed limit optimal evidence-based goal writing.

Limitations

A limitation of this study was that the small convenience sample, taken from a condensed urban and suburban region, limits generalizability to the larger population of school-based physical therapists. There may have been a selection bias based upon the therapists' choice when selecting goals for review. The intent of the training was to take place at the start of the school year (September) and to conclude in June with ample practice for the therapists on site. Because of low enrollment for the first training and requests for additional dates, 2 trainings were subsequently offered (November and January) of the same school year. This offered therapists in later trainings to have less practice versus those in the earlier trainings.

CONCLUSIONS

The results of this study indicate that a structured goal-setting method is effective at improving goal setting that is relevant, context specific, and measurable in the school setting. Although school-based physical therapists in this study were aware of key aspects of effective school-based goal setting, there is a gap in practical application of these aspects when creating goals. The IDEA to GOALS method is a tool to help guide school-based physical therapists to create goals that are aligned with best practice. Implementation of similar methods and changes at the school/district level may help increase effective school-based PT goal setting that is in line with best practice.

ACKNOWLEDGMENTS

The authors thank the following individuals: Elizabeth McAneny, Katrina Long, and Gregory Youdan for assistance with data entry and study management; Stacie Lerro, Kelly Fleming, Karen O'Hagen, Kelly Simon, and Jeanne Martin for assistance with goal scoring; and Maryann Phelps for assistance with training implementation. They also gratefully acknowledge the therapists who participated in the study.

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Keywords:

goal methodology; goal setting; IEP goals; knowledge translation; pediatric physical therapy; school-based

Supplemental Digital Content

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