CURRENT ISSUES
An Educational Intervention to Increase Nurse
Adherence in Eliciting Patient Daily Goals
Kathleen Revello1, BSN, RN, CRRN & Willa Fields2, DNSc, RN, FHIMSS
1 Rehabilitation Unit, Sharp Grossmont Hospital, La Mesa, CA, USA
2 San Diego State University, San Diego, CA, USA
Keywords Abstract
Evidence-based practice; patient daily goals;
education. Background: The literature suggests that nurse and patient collaborative goal
setting demonstrates better patient outcomes. The SMART goal evaluation
Correspondence method (Specific, Measureable, Attainable, Relevant, and Timely) is a strategy
Kathleen Revello, Rehabilitation Educator, to develop effective and measureable goals.
Rehabilitation Unit, Grossmont Hospital,
Purpose: The purpose of this educational project was to improve nurse collab-
5555 Grossmont Center Drive, La Mesa, CA.
orative goal-setting skills.
E-mail: [email protected]
Methods: A pre- and postevaluation of an educational intervention was accom-
Accepted December 7, 2014. plished by patient interviews and observation for adherence to obtaining
patient daily goals.
doi: 10.1002/rnj.201 Results: Results of nurse adherence in writing SMART collaborative goal
setting increased from 11% preeducation to 63% posteducation. Patients’ per-
ceptions 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 setting vague noncollaborative goals and nurses may not
have the skills necessary to write specific collaborative goals
Bodenheimer and Handley (2009) advocated patient goal
(Marsland & Bowman, 2010). The purpose of this educa-
setting as one component to health promotion and chronic
tional project was to improve nurse collaborative goal setting
disease management. Historically, patient goals have been
skills in a mixed medical/surgical and rehabilitation unit.
set by the clinician; however, Fernandez, Rajaratnam,
Evans, and Speizer (2012) suggested that collaborative goal
setting between clinicians and patients is vital to goal
Literature Review
achievement. Collaborative goal setting involves an agree-
ment between the patient and clinician on a health-related CINAHL and PubMed were searched for articles on patient
action plan (Bodenheimer & Handley, 2009), and when daily goals, shared decision making, collaborative goal set-
patients achieve their goals, it suggests they are making ting, and communication. The literature strongly suggested
progress toward discharge (Black, Brock, Kennedy, & Mac- that patient involvement in setting goals enhanced patient
kenzie, 2010). Recent studies indicate that clinicians are outcomes (Bodenheimer & Handley, 2009; Fernandez
© 2015 Association of Rehabilitation Nurses
320 Rehabilitation Nursing 2015, 40, 320–326
K. Revello and W. Fields Eliciting Patient Daily Goals
et al., 2012; Potter & Mueller, 2007). The literature also
Background
suggested when patients achieve a goal, their confidence
increased, and when their confidence increased, their goals This project took place in a 536-bed magnet-designated,
became more ambitious (Bodenheimer & Handley, 2009). acute care hospital, in San Diego County, California, in the
Collaborative goal setting resulted in better adherence 30-bed mixed acute rehabilitation and medical/surgical nurs-
to medication regimes and significantly improved patient ing care unit. The rehabilitation patients’ diagnoses are pri-
outcomes for poorly controlled asthma patients (Wilson marily stroke, nontraumatic head injuries, and spinal cord
et al., 2010) and has also been demonstrated to reduce injuries. There are various diagnoses in the medical/surgical
behavioral risk factors for further cardiac events, improve population, such as cellulitis, diverticulitis, and pneumonia.
physical symptoms, and enhance general well-being in Patient care is provided by registered nurses in con-
cardiac rehabilitation patients (Fernandez et al., 2012). junction with licensed occupational, physical, speech, and
Encouraging patients to move from a passive recipient of respiratory therapists; dieticians; pharmacists; and nursing
care to an involved partner is the desired outcome in assistants. Nurses work 8-hour shifts and care for five
collaborative goal setting. patients with nursing assistant support.
Goal-setting skills are necessary for collaborative goal Relationship-Based Care is the nursing care model. In
setting (Marsland & Bowman, 2010) and time is needed this model the patient and his or her family reside at the
for dialogue between the clinician and patient (Chan, center of the model and all the various components of
Jones, Fung, & Wu, 2012; Say & Thomson, 2003). Nurs- care are organized around their needs in a caring and
ing time constraints have been cited as a barrier to nurse healing environment. Components of relationship-based
and patient collaboration, however, nurses who integrated care include leadership, teamwork, professional nursing,
patient communication during care delivery reported they care delivery, resources, and outcomes (Koloroutis, 2004).
saved time through relationship building and communi- In 2011, based on evidence in the literature, a hospital-
cation (Chan et al., 2012). The combination of an educa- wide initiative on collaborative patient daily goals was
tional program and follow-up support has been implemented. Nurses were informed of this change in prac-
demonstrated to improve clinician goal-writing skills tice through the monthly hospital-wide unit practice coun-
(Marsland & Bowman, 2010). cil, where one nurse from each unit attends and is expected
Several studies found a daily goals worksheet improved to share any new information with peers. A written guide-
clinician knowledge of the patient’s plan of care (Halm, line of the initiative was available on the hospital intranet.
2008; Schwartz, Nelson, Saliski, Hunt, & Pronovost, 2008; The collaborative patient goal-setting initiative required
Timmel et al., 2010), although re-education was needed that after dinner on the day of admission, the nurse asked
to promote sustainability of its use (Schwartz et al., the patient for one or two personal goals he or she hoped
2008). Acute rehabilitation facilities routinely generate to achieve in the following 24-hour period. Goals were
patient goals for an inpatient stay and anticipate the goals informal and not part of the patient’s medical record. The
will be achieved by discharge. All disciplines on the reha- goals were to be realistic and achievable, and the nurse had
bilitation team participate in setting long- and short-term to determine whether necessary resources were available to
goals. Collaborative short-term goal setting has been sug- ensure the goal could be met. For example, if the goal was
gested as a valid measure of patient progress, predicted for the patient to bath himself using a long handled brush,
length of stay, and discharge destination for inpatient the nurse needed to know the patient could safely perform
neurological patients (Black et al., 2010). the activity and adaptive equipment was available.
The SMART Goal Evaluation Method (Doran, 1981) is The following evening, if one or both of the goals were
a strategy to develop effective, measurable goals. Although not met, the patient could elect to continue the previous
first developed for writing management goals, this strategy goals or develop new ones. An example of a goal might
is also appropriate in health care. The SMART Goal Eval- be “I will take only oral pain medications tomorrow” for
uation Method has five domains: Specific, Measurable, a postsurgical patient who was being weaned from intra-
Attainable, Relevant and Timely. Goals should be specific venous pain medication. The patient’s goals were written
to the patient, achievable, and measureable by metric, on the whiteboard in the room and shared in the nursing
quantity, time, or cost effectiveness. In addition, the goal change-in-shift report. The patient’s nurses on other
must be within the patient’s ability and resources to shifts and any therapists working with the patient
achieve and be accomplished within the set time frame. acknowledged the goals with the patient and made an
© 2015 Association of Rehabilitation Nurses
Rehabilitation Nursing 2015, 40, 320–326 321
Eliciting Patient Daily Goals K. Revello and W. Fields
effort to see that the goals were met. This procedure con- was presented in the unit’s conference room. Attendance
tinued until the patient was discharged. was accomplished by scheduling the education before or
Before this initiative, rehabilitation patient goals were gen- after each of the three 8-hour shifts. Nurses, who were
erated by the interdisciplinary team with only minor input unable to attend the education, received individual educa-
from the patient and family. These goals were formal and tion during their shift.
part of the patient’s medical record. The goals were printed The education began by reviewing the organization’s
on a piece of paper and posted in the patient’s room, but the patient daily goals initiative, how evidence suggests patients
goals were not discussed during routine patient care. The who participate in goal setting have higher patient satisfac-
medical and surgical patients, who had short 2–3 day hospi- tion scores and better clinical outcomes, and the SMART
tal stays, were seldom involved in patient goal setting. approach to writing 24-hour patient goals. Each domain of
One year after implementation of the patient goal-setting SMART was discussed and examples of vague versus
initiative, the rehabilitation unit nurse manager observed SMART goals were given to the nurses (see Table 1). After
during patient rounds that goals were absent on the majority the introductory information was presented, the nurses
of patient whiteboards. The nurse educator then assessed nurse were asked for an example of a daily goal. A vague goal
competency on writing goals and adherence with the initiative (e.g., “Decreased back pain”) was evaluated by SMART cri-
by querying nurses and patients and auditing the whiteboards teria, and through group discussion, the goal was rewritten
for presence of patient goals. This assessment demonstrated to meet the SMART criteria (e.g., “Back pain rated 3 of 10
nonadherence with the initiative, and although the nurses sta- with use of oral pain medication”).
ted they knew how to obtain patient goals, they had difficulty The nurses were expected to write patient goals clearly
articulating measurable goals or differentiating between in terms patients and their families could understand. If
short- and long-term goals. When the nurses were asked to possible, the nurses were to refrain from writing goals in
give an example of a patient daily goal, they stated vague, medical terminology. For example, the patient might be
unmeasurable goals such as “I want to feel better” or “I want expecting a hip MRI the next day. Nurses were asked to
to go home.” When questioning patients, the majority of use words like hip “scan” versus “MRI” to assist patients
patients also answered with these vague statements. It was and families to understand the goals. Goals might be as
clear the nurses in the rehabilitation unit needed further edu- simple as having a bowel movement tomorrow or giving
cation on collaborative patient goal setting. their own insulin injection. The goals were to be accom-
plished in 24 hours and were dated so other healthcare
providers could recognize the goals were current and not
Methods
goals from the previous day.
This project utilized a pre and postevaluation of an edu- Collaboration with a patient was practiced through role
cational intervention to improve nurse collaborative goal playing. During the 30-minute educational session the
setting skills. The organization does not require human educator role-played a patient, and the nurses interviewed
subjects review for educational projects. 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,
Educational Intervention
Measurable, Attainable, Realistic, and Time bound goals
The SMART Goal Evaluation Method was incorporated which would help improve patient engagement in his or
into a 30-minute, mandatory educational program which her healthcare decisions. For example, an original patient
Table 1 Examples of vague and SMART patient goals
Examples of Vague Goals SMART Goals (All with Time Frame of 24 hours)
Decrease back pain Back pain rated 3/10 with use of Norco
Increase ambulation Walk in hallway from room to nurses’ station and back to room (100 feet) twice
Increase participation in diabetes care Will give my own insulin injection before breakfast in AM with supervision
Begin bowel program Will have a soft formed stool within 1 hour of suppository given
Increase nutritional status Will eat at least 50% of all meals
Increase independence in grooming Will be able to brush teeth using left hand after nurse sets up supplies
© 2015 Association of Rehabilitation Nurses
322 Rehabilitation Nursing 2015, 40, 320–326
K. Revello and W. Fields Eliciting Patient Daily Goals
goal was “I want to go home.” The nurse then role-played
• Could the patient articulate his or her goals?
with the educator to convert the goal “I want to go home”
to “Tomorrow I will increase my water intake to four
• Could the patient articulate that the nurse collabo-
rated with him or her on their personal goals?
glasses.” For example:
• Did the patient feel well informed by his or her
nurses and physicians?
Patient: “I want to go home.” Data were analyzed with descriptive statistics, and the
Nurse: “Why are you in the hospital?” audit results were also analyzed for differences with a chi
square statistic.
Patient: “I haven’t been taking in enough fluids and the
doctor said I am dehydrated.”
Results
Nurse: “It sounds like you need to increase your fluid intake.”
Thirty-one nurses (78%) attended the in-services. Nurses
Patient: “I drank two cups of water today.”
who did not attend due to sick or vacation leave were
Nurse: “That’s good, however, what if we make a goal that educated individually (n = 9, 22%) when they returned
you will drink four glasses of water tomorrow? Can to work for a final attendance of 40 (100%). All of the
you do that?” nurses rated their satisfaction with the educational
session, their understanding of a SMART goal, and their
Patient: “I will try.”
knowledge of how to obtain a patient goal as excellent.
Nurse: “When you can increase your oral intake to eight Twenty nurses wrote positive statements regarding the
glasses of fluid per day we can get the IV out which SMART goal method, such as “SMART is a good way to
is an important step in getting you home. I will write goals.” Fifteen nurses said “I liked the role playing.”
write your goal on your whiteboard.” 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
Evaluation
(37%) could articulate their goals, 7 (20%) said their
The effectiveness of the intervention was evaluated by an nurse collaborated with them on their goals, and 20
educational evaluation form and an audit for adherence (57%) said they felt well informed by their nurses and
to the daily goals initiative. The evaluation form included physicians (see Figure 1).
three Likert items to be rated (1 = poor, 2 = fair, Four weeks after the nurse educational intervention,
3 = good, and 4 = excellent): please rate your satisfaction patient audits (n = 63) demonstrated improvement in all
with today’s class, please rate your understanding of a areas, although there was an opportunity for further
SMART goal, and please rate your knowledge of how to improvements: 31 (40%) patients had their goal written
obtain a patient goal. The evaluation form also included on their whiteboard, 38 (60%) could articulate their
a space for comments about the educational session. The goals, 33 (52%) said their nurses collaborated with them
form was given to the nurses at the end of the class. on their goals, and 40 (63%) said they felt well informed
Patient rooms were audited for evidence of SMART by their nurses and physician.
patient goals written on the whiteboard, and patients were Based on the 4-week posteducation audit results,
asked to articulate their daily goals, if their nurse had col- follow-up education was provided during the afternoon
laborated with them on their goals, and if they felt well 5-minute “huddles.” During each afternoon huddle, the
informed about their progress. The unit’s nurse educator lead nurse reminded the PM shift nurses to collaborate
assessed the effectiveness of the educational intervention by with each patient to develop a short-term goal for the
evaluating adherence with setting collaborative patient next day. The nurse manager also reinforced obtaining
goals and patient knowledge 1 month preeducation and 1 patient daily goals at her monthly staff meetings. Now
and 4 months posteducation. Yes or no responses to the that the nurses had the skills to elicit patient goals, they
questions were recorded on an audit form consisting of needed to make patient goal setting part of their evening
four items: routine.
• Are the patient’s SMART personal goals written on Results of the patient audits (n = 46) 4 months after
his or her whiteboard? the nurse educational intervention was completed demon-
© 2015 Association of Rehabilitation Nurses
Rehabilitation Nursing 2015, 40, 320–326 323
Eliciting Patient Daily Goals K. Revello and W. Fields
100
90 ***
80
70
60
***
**
50 *
percent
40
***
30
20 ***
10 ***
0
goals on whiteboard paent arculate goals nurse collaborated with paent paent well informed
* p < .05 preeducaon one month post 4 months post
** p < .01
*** p < .001
Figure 1 Compliance with patient daily goals initiative.
strated that 29 (63%) of the patients had their goals writ- skills since the goals written on the whiteboards were
ten on their whiteboard, 31 (67%) could articulate their short-term SMART goals.
goals, 31 (67%) said their nurse collaborated with them Audits revealed nursing adherence in obtaining their
on their goals, and 42 (91%) said they felt well informed patient’s daily goals had increased, but not sufficiently.
by their nurses and physician. The unit has continued its goal of 90% adherence in the
The chi square statistic (see Figure 1) demonstrated four areas of the audit tool: goals are written on the
that the baseline results were statistically lower than sub- whiteboard, the patient can articulate his or her goals, the
sequent audits for all questions. At 1 month posteduca- patient can articulate the nurse collaborated with him or
tion, the audit demonstrated statistically higher results her on these goals, and the patient feels well informed.
than baseline and lower results than the 4-month audit Changing healthcare practice is a complex process that
for patient goals written on the whiteboard and patients may take months or even years to occur, so the challenge
felt well informed by their nurses and physicians. At for educators is to not only impart knowledge but also
4 months posteducation, the audit demonstrated statisti- assist in behavior change (McCluskey & Lovarini, 2005).
cally higher results than baseline and 1 month posteduca- The unit’s educator has become a change agent for
tion for only patients felt well informed by their nurses sustaining and increasing adherence with the patient daily
and physicians. 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.
Discussion and Nursing Implications
Audits will be repeated monthly and continued until
The goal of this educational intervention was to increase nursing adherence is at least 90% for 6 months. In a
nurses’ goal-setting skills. Since the nurses had knowledge program utilizing a daily goals sheet, Schwartz et al.
in the creation of SMART goals, adherence with collabo- (2008) specified auditing and re-education was needed to
rative goal setting with each patient was the expectation. support their change in practice. If results are below 70%,
However, 4 months after the educational intervention re-education will be done in the change-of-shift huddle.
nurse adherence with daily goal setting had only reached Obtaining patient goals is a simple and a cost-effective
63%. The educator and unit manager set a future goal of method of increasing patient goal attainment, but the
90% for all of the audit components. The educational challenge remains in motivating the nurses to follow the
intervention did improve nursing skill in goal-writing initiative. Education alone may not be sufficient to
© 2015 Association of Rehabilitation Nurses
324 Rehabilitation Nursing 2015, 40, 320–326
K. Revello and W. Fields Eliciting Patient Daily Goals
Key Practice Points progress in inpatient neurological rehabilitation? Clinical
Nurses need education to write collaborative patient goals Rehabilitation, 24(4), 373–379.
and reminded of their importance. Bodenheimer, T., & Handley, M. (2009). Goal-setting for
behavior change in primary care: An exploration and
Nurses utilized the SMART method to write patient goals.
status report. Patient Education and Counseling, 76(2),
Patient goals should be collaborative. 174–180.
Chan, E., Jones, A., Fung, S., & Wu, S. (2012). Nurses’
When patients achieve goals, their confidence increases.
perception of time availability in patient communication
in Hong Kong. Journal of Clinical Nursing, 21(7/8),
1168–1177.
sustain adherence; better results may be obtained when
Doran, G. T. (1981). There’s a S.M.A.R.T. way to write
education is combined with follow-up support (Marsland
management’s goals and objectives. Management Review,
& Bowman, 2010). Follow-up support will include nurse
70(11), 35–36.
rounding, posters to reinforce the guideline, and having
Fernandez, R., Rajaratnam, R., Evans, K., & Speizer, A. (2012).
the manager of the unit reinforce the practice of obtain-
Goal setting in cardiac rehabilitation: Implications for
ing daily patient goals at staff meetings.
clinical practice. Contemporary Nurse, 43(1), 13–21.
There were several limitations in this educational inter- Halm, M. (2008). Daily goals worksheets and other checklists:
vention. This education was only conducted on one unit Are our critical care units safer? American Journal of Critical
at one hospital and cannot be generalized to other areas. Care, 17(6), 577–580.
The project was conducted over a 6-month period, so it Koloroutis, M. (Ed.) (2004). Relationship-based care: A model
is difficult to determine if the education and SMART goal for transforming practice. Minneapolis, MN: Creative
setting was firmly entrenched into the nurses’ daily rou- Health Care Management.
tine. Also, it was not possible to see if the intervention Marsland, E., & Bowman, J. (2010). An interactive education
enhanced patient clinical outcomes, increased patient session and follow-up support as a strategy to improve
confidence, increased better adherence to the medical clinicians’ goal-writing skills: A randomized controlled
plan, or decreased behavioral risk factors. Although these trial. Journal of Evaluation in Clinical Practice, 16,
limitations existed, the results demonstrated that a 3–13.
combination of an educational intervention with follow-up McCluskey, A., & Lovarini, M. (2005). Providing education on
enhanced nurse’s goal-setting skills. evidenced-based practice improved knowledge but did not
change behavior: A before and after study. BMC Medical
Education, 5(40), 1–12.
Conclusion Potter, P., & Mueller, J. (2007). How well do you know your
This educational intervention increased nurse’s collabora- patients? Nursing Management, 38(2), 40–48.
tive goal-setting skills. Huddle and staff meeting remind- Say, R., & Thomson, R. (2003). The importance of patient
preferences in treatment decisions—challenges for doctors.
ers increased nurse adherence in obtaining their patient’s
British Medical Journal, 327(7414), 542–545.
daily goals. Collaboration between patients and nurses
Schwartz, J., Nelson, K., Saliski, M., Hunt, E., & Pronovost, P.
can assist patients in making progress toward discharge.
(2008). The daily goals communication sheet: A simple and
It is essential for nurses to collaborate with their patients
novel tool for improved communication and care. The Joint
to create specific, measurable, attainable, relevant, and
Commission Journal on Quality and Patient Safety, 34(10),
timely (SMART) short-term goals. Ongoing research
608–613.
utilizing SMART goals can provide more insight into
Timmel, J., Kent, P., Holzmueller, C., Paine, L., Schulick, R.,
patient daily goals and patient confidence with healthcare & Pronovost, P. (2010). Impact of the comprehensive unit-
providers. Further research is needed to evaluate the based safety program (CUSP) on safety culture in a surgical
relationship between obtaining patient daily goals, patient inpatient unit. The Joint Commission Journal on Quality and
satisfaction, and outcomes. Patient Safety, 36(6), 252–260.
Wilson, S., Strub, P., Buist, S., Knowles, S., Lavori, P.,
Lapidus, J., & Vollmer, W. (2010). Shared treatment
References
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© 2015 Association of Rehabilitation Nurses
Rehabilitation Nursing 2015, 40, 320–326 325
Eliciting Patient Daily Goals K. Revello and W. Fields
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