An Educational Intervention to Increase Nurse Adherence in Eliciting Patient Daily Goals

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1 CURRENT ISSUES An Educational Intervention to Increase Nurse Adherence in Eliciting Patient Daily Goals Kathleen Revello 1, BSN, RN, CRRN & Willa Fields 2, DNSc, RN, FHIMSS 1 Rehabilitation Unit, Sharp Grossmont Hospital, La Mesa, CA, USA 2 San Diego State University, San Diego, CA, USA Keywords Evidence-based practice; patient daily goals; education. Correspondence Kathleen Revello, Rehabilitation Educator, Rehabilitation Unit, Grossmont Hospital, 5555 Grossmont Center Drive, La Mesa, CA. katie.revello@sharp.com Accepted December 7, doi: /rnj.201 Abstract Background: The literature suggests that nurse and patient collaborative goal setting demonstrates better patient outcomes. The SMART goal evaluation method (Specific, Measureable, Attainable, Relevant, and Timely) is a strategy to develop effective and measureable goals. Purpose: The purpose of this educational project was to improve nurse collaborative goal-setting skills. Methods: A pre- and postevaluation of an educational intervention was accomplished by patient interviews and observation for adherence to obtaining patient daily goals. Results: Results of nurse adherence in writing SMART collaborative goal setting increased from 11% preeducation to 63% posteducation. Patients perceptions of feeling well informed by their nurses and physicians increased from 57% preeducation to 91% posteducation. Conclusion: Nurses continued to need reminding to collaborate with their patients, but their goal writing skills greatly improved. Clinical Relevance: The results of this educational project demonstrated nurses improved ability to cowrite collaborative patient goals which resulted in better informed patients. Introduction Bodenheimer and Handley (2009) advocated patient goal setting as one component to health promotion and chronic disease management. Historically, patient goals have been set by the clinician; however, Fernandez, Rajaratnam, Evans, and Speizer (2012) suggested that collaborative goal setting between clinicians and patients is vital to goal achievement. Collaborative goal setting involves an agreement between the patient and clinician on a health-related action plan (Bodenheimer & Handley, 2009), and when patients achieve their goals, it suggests they are making progress toward discharge (Black, Brock, Kennedy, & Mackenzie, 2010). Recent studies indicate that clinicians are setting vague noncollaborative goals and nurses may not have the skills necessary to write specific collaborative goals (Marsland & Bowman, 2010). The purpose of this educational project was to improve nurse collaborative goal setting skills in a mixed medical/surgical and rehabilitation unit. Literature Review CINAHL and PubMed were searched for articles on patient daily goals, shared decision making, collaborative goal setting, and communication. The literature strongly suggested that patient involvement in setting goals enhanced patient outcomes (Bodenheimer & Handley, 2009; Fernandez 320

2 K. Revello and W. Fields Eliciting Patient Daily Goals et al., 2012; Potter & Mueller, 2007). The literature also suggested when patients achieve a goal, their confidence increased, and when their confidence increased, their goals became more ambitious (Bodenheimer & Handley, 2009). Collaborative goal setting resulted in better adherence to medication regimes and significantly improved patient outcomes for poorly controlled asthma patients (Wilson et al., 2010) and has also been demonstrated to reduce behavioral risk factors for further cardiac events, improve physical symptoms, and enhance general well-being in cardiac rehabilitation patients (Fernandez et al., 2012). Encouraging patients to move from a passive recipient of care to an involved partner is the desired outcome in collaborative goal setting. Goal-setting skills are necessary for collaborative goal setting (Marsland & Bowman, 2010) and time is needed for dialogue between the clinician and patient (Chan, Jones, Fung, & Wu, 2012; Say & Thomson, 2003). Nursing time constraints have been cited as a barrier to nurse and patient collaboration, however, nurses who integrated patient communication during care delivery reported they saved time through relationship building and communication (Chan et al., 2012). The combination of an educational program and follow-up support has been demonstrated to improve clinician goal-writing skills (Marsland & Bowman, 2010). Several studies found a daily goals worksheet improved clinician knowledge of the patient s plan of care (Halm, 2008; Schwartz, Nelson, Saliski, Hunt, & Pronovost, 2008; Timmel et al., 2010), although re-education was needed to promote sustainability of its use (Schwartz et al., 2008). Acute rehabilitation facilities routinely generate patient goals for an inpatient stay and anticipate the goals will be achieved by discharge. All disciplines on the rehabilitation team participate in setting long- and short-term goals. Collaborative short-term goal setting has been suggested as a valid measure of patient progress, predicted length of stay, and discharge destination for inpatient neurological patients (Black et al., 2010). The SMART Goal Evaluation Method (Doran, 1981) is a strategy to develop effective, measurable goals. Although first developed for writing management goals, this strategy is also appropriate in health care. The SMART Goal Evaluation Method has five domains: Specific, Measurable, Attainable, Relevant and Timely. Goals should be specific to the patient, achievable, and measureable by metric, quantity, time, or cost effectiveness. In addition, the goal must be within the patient s ability and resources to achieve and be accomplished within the set time frame. Background This project took place in a 536-bed magnet-designated, acute care hospital, in San Diego County, California, in the 30-bed mixed acute rehabilitation and medical/surgical nursing care unit. The rehabilitation patients diagnoses are primarily stroke, nontraumatic head injuries, and spinal cord injuries. There are various diagnoses in the medical/surgical population, such as cellulitis, diverticulitis, and pneumonia. Patient care is provided by registered nurses in conjunction with licensed occupational, physical, speech, and respiratory therapists; dieticians; pharmacists; and nursing assistants. Nurses work 8-hour shifts and care for five patients with nursing assistant support. Relationship-Based Care is the nursing care model. In this model the patient and his or her family reside at the center of the model and all the various components of care are organized around their needs in a caring and healing environment. Components of relationship-based care include leadership, teamwork, professional nursing, care delivery, resources, and outcomes (Koloroutis, 2004). In 2011, based on evidence in the literature, a hospitalwide initiative on collaborative patient daily goals was implemented. Nurses were informed of this change in practice through the monthly hospital-wide unit practice council, where one nurse from each unit attends and is expected to share any new information with peers. A written guideline of the initiative was available on the hospital intranet. The collaborative patient goal-setting initiative required that after dinner on the day of admission, the nurse asked the patient for one or two personal goals he or she hoped to achieve in the following 24-hour period. Goals were informal and not part of the patient s medical record. The goals were to be realistic and achievable, and the nurse had to determine whether necessary resources were available to ensure the goal could be met. For example, if the goal was for the patient to bath himself using a long handled brush, the nurse needed to know the patient could safely perform the activity and adaptive equipment was available. The following evening, if one or both of the goals were not met, the patient could elect to continue the previous goals or develop new ones. An example of a goal might be I will take only oral pain medications tomorrow for a postsurgical patient who was being weaned from intravenous pain medication. The patient s goals were written on the whiteboard in the room and shared in the nursing change-in-shift report. The patient s nurses on other shifts and any therapists working with the patient acknowledged the goals with the patient and made an 321

3 Eliciting Patient Daily Goals K. Revello and W. Fields effort to see that the goals were met. This procedure continued until the patient was discharged. Before this initiative, rehabilitation patient goals were generated by the interdisciplinary team with only minor input from the patient and family. These goals were formal and part of the patient s medical record. The goals were printed on a piece of paper and posted in the patient s room, but the goals were not discussed during routine patient care. The medical and surgical patients, who had short 2 3 day hospital stays, were seldom involved in patient goal setting. One year after implementation of the patient goal-setting initiative, the rehabilitation unit nurse manager observed during patient rounds that goals were absent on the majority of patient whiteboards. The nurse educator then assessed nurse competency on writing goals and adherence with the initiative by querying nurses and patients and auditing the whiteboards for presence of patient goals. This assessment demonstrated nonadherence with the initiative, and although the nurses stated they knew how to obtain patient goals, they had difficulty articulating measurable goals or differentiating between short- and long-term goals. When the nurses were asked to give an example of a patient daily goal, they stated vague, unmeasurable goals such as I want to feel better or I want to go home. When questioning patients, the majority of patients also answered with these vague statements. It was clear the nurses in the rehabilitation unit needed further education on collaborative patient goal setting. Methods This project utilized a pre and postevaluation of an educational intervention to improve nurse collaborative goal setting skills. The organization does not require human subjects review for educational projects. Educational Intervention The SMART Goal Evaluation Method was incorporated into a 30-minute, mandatory educational program which was presented in the unit s conference room. Attendance was accomplished by scheduling the education before or after each of the three 8-hour shifts. Nurses, who were unable to attend the education, received individual education during their shift. The education began by reviewing the organization s patient daily goals initiative, how evidence suggests patients who participate in goal setting have higher patient satisfaction scores and better clinical outcomes, and the SMART approach to writing 24-hour patient goals. Each domain of SMART was discussed and examples of vague versus SMART goals were given to the nurses (see Table 1). After the introductory information was presented, the nurses were asked for an example of a daily goal. A vague goal (e.g., Decreased back pain ) was evaluated by SMART criteria, and through group discussion, the goal was rewritten to meet the SMART criteria (e.g., Back pain rated 3 of 10 with use of oral pain medication ). The nurses were expected to write patient goals clearly in terms patients and their families could understand. If possible, the nurses were to refrain from writing goals in medical terminology. For example, the patient might be expecting a hip MRI the next day. Nurses were asked to use words like hip scan versus MRI to assist patients and families to understand the goals. Goals might be as simple as having a bowel movement tomorrow or giving their own insulin injection. The goals were to be accomplished in 24 hours and were dated so other healthcare providers could recognize the goals were current and not goals from the previous day. Collaboration with a patient was practiced through role playing. During the 30-minute educational session the educator role-played a patient, and the nurses interviewed her to elicit a short-term goal. The educator gave vague responses to their questions, which allowed the nurses to practice collaborating with patients to develop Specific, Measurable, Attainable, Realistic, and Time bound goals which would help improve patient engagement in his or her healthcare decisions. For example, an original patient Table 1 Examples of vague and SMART patient goals Examples of Vague Goals Decrease back pain Increase ambulation Increase participation in diabetes care Begin bowel program Increase nutritional status Increase independence in grooming SMART Goals (All with Time Frame of 24 hours) Back pain rated 3/10 with use of Norco Walk in hallway from room to nurses station and back to room (100 feet) twice Will give my own insulin injection before breakfast in AM with supervision Will have a soft formed stool within 1 hour of suppository given Will eat at least 50% of all meals Will be able to brush teeth using left hand after nurse sets up supplies 322

4 K. Revello and W. Fields Eliciting Patient Daily Goals goal was I want to go home. The nurse then role-played with the educator to convert the goal I want to go home to Tomorrow I will increase my water intake to four glasses. For example: Patient: I want to go home. Nurse: Why are you in the hospital? Patient: I haven t been taking in enough fluids and the doctor said I am dehydrated. Nurse: It sounds like you need to increase your fluid intake. Patient: I drank two cups of water today. Nurse: That s good, however, what if we make a goal that you will drink four glasses of water tomorrow? Can you do that? Patient: I will try. Nurse: When you can increase your oral intake to eight glasses of fluid per day we can get the IV out which is an important step in getting you home. I will write your goal on your whiteboard. Evaluation The effectiveness of the intervention was evaluated by an educational evaluation form and an audit for adherence to the daily goals initiative. The evaluation form included three Likert items to be rated (1 = poor, 2 = fair, 3 = good, and 4 = excellent): please rate your satisfaction with today s class, please rate your understanding of a SMART goal, and please rate your knowledge of how to obtain a patient goal. The evaluation form also included a space for comments about the educational session. The form was given to the nurses at the end of the class. Patient rooms were audited for evidence of SMART patient goals written on the whiteboard, and patients were asked to articulate their daily goals, if their nurse had collaborated with them on their goals, and if they felt well informed about their progress. The unit s nurse educator assessed the effectiveness of the educational intervention by evaluating adherence with setting collaborative patient goals and patient knowledge 1 month preeducation and 1 and 4 months posteducation. Yes or no responses to the questions were recorded on an audit form consisting of four items: Are the patient s SMART personal goals written on his or her whiteboard? Could the patient articulate his or her goals? Could the patient articulate that the nurse collaborated with him or her on their personal goals? Did the patient feel well informed by his or her nurses and physicians? Data were analyzed with descriptive statistics, and the audit results were also analyzed for differences with a chi square statistic. Results Thirty-one nurses (78%) attended the in-services. Nurses who did not attend due to sick or vacation leave were educated individually (n = 9, 22%) when they returned to work for a final attendance of 40 (100%). All of the nurses rated their satisfaction with the educational session, their understanding of a SMART goal, and their knowledge of how to obtain a patient goal as excellent. Twenty nurses wrote positive statements regarding the SMART goal method, such as SMART is a good way to write goals. Fifteen nurses said I liked the role playing. Results of the patient audits (n = 35) 1 month before the nurse educational intervention demonstrated 4 (11%) patients had their goals written on the whiteboard, 13 (37%) could articulate their goals, 7 (20%) said their nurse collaborated with them on their goals, and 20 (57%) said they felt well informed by their nurses and physicians (see Figure 1). Four weeks after the nurse educational intervention, patient audits (n = 63) demonstrated improvement in all areas, although there was an opportunity for further improvements: 31 (40%) patients had their goal written on their whiteboard, 38 (60%) could articulate their goals, 33 (52%) said their nurses collaborated with them on their goals, and 40 (63%) said they felt well informed by their nurses and physician. Based on the 4-week posteducation audit results, follow-up education was provided during the afternoon 5-minute huddles. During each afternoon huddle, the lead nurse reminded the PM shift nurses to collaborate with each patient to develop a short-term goal for the next day. The nurse manager also reinforced obtaining patient daily goals at her monthly staff meetings. Now that the nurses had the skills to elicit patient goals, they needed to make patient goal setting part of their evening routine. Results of the patient audits (n = 46) 4 months after the nurse educational intervention was completed demon- 323

5 Eliciting Patient Daily Goals K. Revello and W. Fields * ** percent * p <.05 ** p <.01 p <.001 goals on whiteboard pa ent ar culate goals nurse collaborated with pa ent pa ent well informed preeduca on one month post 4 months post Figure 1 Compliance with patient daily goals initiative. strated that 29 (63%) of the patients had their goals written on their whiteboard, 31 (67%) could articulate their goals, 31 (67%) said their nurse collaborated with them on their goals, and 42 (91%) said they felt well informed by their nurses and physician. The chi square statistic (see Figure 1) demonstrated that the baseline results were statistically lower than subsequent audits for all questions. At 1 month posteducation, the audit demonstrated statistically higher results than baseline and lower results than the 4-month audit for patient goals written on the whiteboard and patients felt well informed by their nurses and physicians. At 4 months posteducation, the audit demonstrated statistically higher results than baseline and 1 month posteducation for only patients felt well informed by their nurses and physicians. Discussion and Nursing Implications The goal of this educational intervention was to increase nurses goal-setting skills. Since the nurses had knowledge in the creation of SMART goals, adherence with collaborative goal setting with each patient was the expectation. However, 4 months after the educational intervention nurse adherence with daily goal setting had only reached 63%. The educator and unit manager set a future goal of 90% for all of the audit components. The educational intervention did improve nursing skill in goal-writing skills since the goals written on the whiteboards were short-term SMART goals. Audits revealed nursing adherence in obtaining their patient s daily goals had increased, but not sufficiently. The unit has continued its goal of 90% adherence in the four areas of the audit tool: goals are written on the whiteboard, the patient can articulate his or her goals, the patient can articulate the nurse collaborated with him or her on these goals, and the patient feels well informed. Changing healthcare practice is a complex process that may take months or even years to occur, so the challenge for educators is to not only impart knowledge but also assist in behavior change (McCluskey & Lovarini, 2005). The unit s educator has become a change agent for sustaining and increasing adherence with the patient daily goals initiative and believes this goal can be accomplished over time. Routinely auditing and sharing the results of the audits with the nurses will help sustain the initiative. Audits will be repeated monthly and continued until nursing adherence is at least 90% for 6 months. In a program utilizing a daily goals sheet, Schwartz et al. (2008) specified auditing and re-education was needed to support their change in practice. If results are below 70%, re-education will be done in the change-of-shift huddle. Obtaining patient goals is a simple and a cost-effective method of increasing patient goal attainment, but the challenge remains in motivating the nurses to follow the initiative. Education alone may not be sufficient to 324

6 K. Revello and W. Fields Eliciting Patient Daily Goals Key Practice Points Nurses need education to write collaborative patient goals and reminded of their importance. Nurses utilized the SMART method to write patient goals. Patient goals should be collaborative. When patients achieve goals, their confidence increases. sustain adherence; better results may be obtained when education is combined with follow-up support (Marsland & Bowman, 2010). Follow-up support will include nurse rounding, posters to reinforce the guideline, and having the manager of the unit reinforce the practice of obtaining daily patient goals at staff meetings. There were several limitations in this educational intervention. This education was only conducted on one unit at one hospital and cannot be generalized to other areas. The project was conducted over a 6-month period, so it is difficult to determine if the education and SMART goal setting was firmly entrenched into the nurses daily routine. Also, it was not possible to see if the intervention enhanced patient clinical outcomes, increased patient confidence, increased better adherence to the medical plan, or decreased behavioral risk factors. Although these limitations existed, the results demonstrated that a combination of an educational intervention with follow-up enhanced nurse s goal-setting skills. Conclusion This educational intervention increased nurse s collaborative goal-setting skills. Huddle and staff meeting reminders increased nurse adherence in obtaining their patient s daily goals. Collaboration between patients and nurses can assist patients in making progress toward discharge. It is essential for nurses to collaborate with their patients to create specific, measurable, attainable, relevant, and timely (SMART) short-term goals. Ongoing research utilizing SMART goals can provide more insight into patient daily goals and patient confidence with healthcare providers. Further research is needed to evaluate the relationship between obtaining patient daily goals, patient satisfaction, and outcomes. References Black, S., Brock, K., Kennedy, G., & Mackenzie, M. (2010). Is achievement of short-term goals a valid measure of patient progress in inpatient neurological rehabilitation? Clinical Rehabilitation, 24(4), Bodenheimer, T., & Handley, M. (2009). Goal-setting for behavior change in primary care: An exploration and status report. Patient Education and Counseling, 76(2), Chan, E., Jones, A., Fung, S., & Wu, S. (2012). Nurses perception of time availability in patient communication in Hong Kong. Journal of Clinical Nursing, 21(7/8), Doran, G. T. (1981). There s a S.M.A.R.T. way to write management s goals and objectives. Management Review, 70(11), Fernandez, R., Rajaratnam, R., Evans, K., & Speizer, A. (2012). Goal setting in cardiac rehabilitation: Implications for clinical practice. Contemporary Nurse, 43(1), Halm, M. (2008). Daily goals worksheets and other checklists: Are our critical care units safer? American Journal of Critical Care, 17(6), Koloroutis, M. (Ed.) (2004). Relationship-based care: A model for transforming practice. Minneapolis, MN: Creative Health Care Management. Marsland, E., & Bowman, J. (2010). An interactive education session and follow-up support as a strategy to improve clinicians goal-writing skills: A randomized controlled trial. Journal of Evaluation in Clinical Practice, 16, McCluskey, A., & Lovarini, M. (2005). Providing education on evidenced-based practice improved knowledge but did not change behavior: A before and after study. BMC Medical Education, 5(40), Potter, P., & Mueller, J. (2007). How well do you know your patients? Nursing Management, 38(2), Say, R., & Thomson, R. (2003). The importance of patient preferences in treatment decisions challenges for doctors. British Medical Journal, 327(7414), Schwartz, J., Nelson, K., Saliski, M., Hunt, E., & Pronovost, P. (2008). The daily goals communication sheet: A simple and novel tool for improved communication and care. The Joint Commission Journal on Quality and Patient Safety, 34(10), Timmel, J., Kent, P., Holzmueller, C., Paine, L., Schulick, R., & Pronovost, P. (2010). Impact of the comprehensive unitbased safety program (CUSP) on safety culture in a surgical inpatient unit. The Joint Commission Journal on Quality and Patient Safety, 36(6), Wilson, S., Strub, P., Buist, S., Knowles, S., Lavori, P., Lapidus, J., & Vollmer, W. (2010). Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. American Journal of Respiratory and Critical Care Medicine, 181(6),

7 Eliciting Patient Daily Goals K. Revello and W. Fields Earn nursing contact hours Rehabilitation Nursing is pleased to offer readers the opportunity to earn nursing contact hours for its continuing education articles by taking a posttest through the ARN website. The posttest consists of questions based on thisarticle, plus several assessment questions (e.g., how long did it take you to read the articles and complete the posttest?). A passing score on the posttest and completing of the assessment questions yield one nursing contact hour for each article. To earn contact hours, go to and select the Education page. There you can read the article again, or go directly to the posttest assessment by selecting RNJ online CE. The cost for credit is $10 per article. You will be asked for a credit card or online payment service number. The contact hours for this activity will not be available after October 31, The Association of Rehabilitation Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation (ANCC-COA). 326