Older Adults’ Experiences of Goals in Health: A Systematic Review and Metasynthesis

Abstract

Objective: To synthesize older adults’ experiences and perceptions of goal setting and pursuit within health systems. Methods: Six databases were searched to May 2019 using a combination of MeSH and free text terms. Included papers were written in English and reported original qualitative research for participants aged 65 years and older. Participant quotes from the results sections of included studies were gathered for thematic analysis and synthesis. Results: Initial search yielded 9,845 articles, and 134 were identified for full-text review. Fifteen papers were included in the final synthesis. Two main themes were identified: enablers (intrinsic and extrinsic) and barriers (personal and system). Conclusion: Older adults’ self-belief is the strongest enabler for goal activities, enhanced by a personalized coaching approach from health staff. Conversely, inconsistent goal terminology confuses patients and reduces engagement. Likewise, fatigue has profound physical and cognitive impact on patients’ ability to engage and participate in goals.

Keywords

goals aged self-efficacy qualitative research review systematic review

Introduction

Older adults are at risk of losing function when admitted to hospital due to a range of factors, including an environment that promotes bed rest and a reduction in nutritional intake or hydration. These can affect energy levels and, therefore, the ability to participate in treatment and recovery (Grill et al., 2005). Bed rest, inactivity, and suboptimal nutrition or hydration contribute to increased risk of physical or cognitive decline (Iwashyna et al., 2010). Cognitive decline is also associated with increased rates of depression and a perceived inability to achieve goals (Street et al., 2007). Goal setting occurs throughout the patient’s journey in the health system, from the hyperacute emergency department, through the hospital, to subacute services and back into the community. Goals should provide an opportunity for shared decision-making and person-centered care (Bachmann et al., 2010) to enhance motivation and engagement and improve self-efficacy (Levack et al., 2016). Goal setting is considered the method for identifying and negotiating goals and can inform symptom management, therapy intervention, functional status, or return to social activities (Levack & Siegert, 2015). Goals are facilitated by shared decision-making, where the health care practitioner (HCP) provides expertise regarding the different options and processes available (Hoffmann et al., 2018) and the patient brings expertise of their life, situation, and expectations. The literature is clear that goal setting with older patients enhances functional ability (Kus et al., 2011), life satisfaction (Åberg, 2008), self-reported quality of life, emotional status and self-efficacy (Levack et al., 2016), increased function, reduced nursing home admissions, and reduced mortality (Bachmann et al., 2010). The benefits of goal setting in rehabilitation (Levack et al., 2016) have been confirmed for specific conditions such as stroke (Rosewilliam et al., 2011; Sugavanam et al., 2013), polyarthritis (Arends et al., 2013, 2016), acquired brain injury (Plant et al., 2016), and cancer (Rose et al., 2004). Despite the depth of literature on goals in rehabilitation and the importance of functional maintenance goals for older adults (Ebner et al., 2006), there is limited literature exploring older patients’ perceptions or experiences of goal setting and attainment in the health setting. The aim of this review was, therefore, to identify older adults’ perspectives and experiences of goal setting and pursuit within the health system.

Method

This systematic review is registered in the international prospective register of systematic reviews (PROSPERO) ID:CRD42017064382. The metasynthesis process of analyzing included papers followed procedures outlined by Sandelowski and Barroso (2006).

Search Strategy and Selection of Included Articles

Keywords for searching were based on three themes with search terms adapted for each database: patient goals, including setting, pursuit, and attainment; older adults; and patient experience or perception. A detailed search strategy for MEDLINE is presented in Appendix. A search was conducted in CINAHL, MEDLINE, Scopus, PubMed, PsycInfo, AgeLine, and EmCare databases from 1966 to May 2019 with assistance from an expert librarian. Inclusion criteria were primary research articles of any design written in English that investigated experiences and/or perceptions of goal setting, attainment, or pursuit, within the health context, of adults aged 65 years and older. Exclusion criteria were for articles that did not report primary research, were not in the health setting, were not patient experience or patient goals, and data were unable to be extracted for patients aged 65 years or older when there were mixed age groups or mixed patient, staff, and carer participants.

Data Collection and Analysis

The primary author (N.B.) reviewed all titles and three independent reviewers (S.G., S.L., and S.J.G.) each reviewed one third of selected titles for relevance, applying the inclusion and exclusion criteria. Potentially relevant papers were subjected to abstract review. Three members of the team (N.B., S.L., and S.G.) reviewed each abstract against inclusion and exclusion criteria, and full articles were retrieved for those papers deemed relevant. In addition, reference lists were screened from the acquired papers and systematic reviews identified in this search. Full-text articles were identified for inclusion, and discrepancies were resolved through discussion or third member mediation at each stage. Methodological quality of the selected studies was measured with the Leeds Mixed Methods (Long et al., 2002) or Critical Appraisal Skills Program (CASP, 2016) qualitative critical appraisal tools. The primary author (N.B.) appraised all articles, and the three other authors appraised one third each. The primary author (N.B.) extracted into NVivo 11 (QSR, 2015) all direct participant quotes from the selected papers and an independent reviewer (S.G.) checked them for accuracy and completeness.

Concepts relevant to older adults’ perceptions and experiences of goal setting and pursuit were identified within each paper before grouping words, sentences, or quotes into common themes and concepts. These were compared and discussed against the original works by two independent reviewers (N.B. and S.G.) and presented to the other team members at monthly meetings until agreement was reached. An audit trail was maintained through note-taking and presented to the other team members for group discussion, alternate interpretations, and consensus.

Results

Search Results

The search is described in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart (Moher et al., 2015), Figure 1.

Figure 1.

PRISMA 2009 flow diagram.

Characteristics of Included Studies

Table 1 incorporates the characteristics and quality appraisal of the included studies. There were n = 764 participants (age range: 65–100 years, M: 78 years; 64% female) included in the 15 studies, three mixed methods studies (Melville et al., 2002; Rose et al., 2019; Saajanaho et al., 2016) and 12 qualitative studies (Brown et al., 2014; Coylewright et al., 2016; Efraimsson et al., 2006; Feder et al., 2019; Gorawara-Bhat et al., 2008; Hjelle et al., 2016; Huang et al., 2005; Kuluski et al., 2013; Pikkarainen et al., 2018; Schellinger et al., 2018; Schulman-Green et al., 2006; van Seben et al., 2019). Most studies chose purposive sampling. Data collection was via interviews (Brown et al., 2014; Efraimsson et al., 2006; Feder et al., 2019; Gorawara-Bhat et al., 2008; Hjelle et al., 2016; Huang et al., 2005; Kuluski et al., 2013; van Seben et al., 2019), questionnaires (Saajanaho et al., 2016; Schulman-Green et al., 2006), or a combination of both (Coylewright et al., 2016; Melville et al., 2002; Rose et al., 2019). Pikkarainen et al. (2018) used nonparticipant observation, and Schellinger et al. (2018) analyzed the data from electronic medical records that had documented direct patient quotes or patient validated statements. The papers collectively depicted a longitudinal journey through the health system, from the acute hospital setting (Coylewright et al., 2016; Efraimsson et al., 2006) through subacute and rehabilitation (Brown et al., 2014; Melville et al., 2002; Pikkarainen et al., 2018; van Seben et al., 2019), outpatients (Gorawara-Bhat et al., 2008; Huang et al., 2005; Kuluski et al., 2013), and back into the community (Feder et al., 2019; Hjelle et al., 2016; Rose et al., 2019; Saajanaho et al., 2016; Schellinger et al., 2018; Schulman-Green et al., 2006; van Seben et al., 2019). The research was conducted in various countries—see Table 1 for characteristics and quality appraisal.

Table 1.

Characteristics and Quality Appraisal.

Author (year)	Country	Setting	Patients aged 65 years and older, n	Aims clearly stated	Research design appropriate	Recruitment strategy appropriate	Appropriate data collection method	Potential bias addressed	Ethics approval	Analytical rigor	Clear statement of findings	Clinical or policy relevance	Credibility	Dependability	Transferability	Confirmability
Brown et al. (2014)	New Zealand	Rehab	4 (of 10 participants)	Y	Y	Y	Y	—	Y	Y	Y	Y	Y	Y	—	Y
Coylewright et al. (2016)	United States	Hospital	46	Y	Y	Y	Y	—	Y	Y	Y	Y	Y	Y	—	Y
Efraimsson et al. (2006)	Sweden	Hospital	7	Y	Y	—	—	Y	Y	Y	Y	Y	Y	Y	—	Y
Feder et al. (2019)	United States	Community	22	Y	Y	Y	Y	—	Y	Y	Y	Y	Y	Y	—	Y
Gorawara-Bhat et al. (2008)	United States	OP	28	Y	Y	—	Y	—	Y	Y	Y	Y	Y	Y	—	Y
Hjelle et al. (2016)	Norway	Community	7 (of 8 participants)	Y	Y	Y	Y	—	Y	Y	Y	Y	Y	Y	—	—
Huang et al. (2005)	United States	OP	28	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	—	Y
Kuluski et al. (2013)	Canada	Community	28	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	—	Y
Melville et al. (2002)	United States	Hospital	30	Y	Y	Y	Y	—	Y	—	—	—	Y	Y	—	Y
Pikkarainen et al. (2018)	Finland	Community	38	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	—	Y
Rose et al. (2019)	United Kingdom	Community	9 (of 40 pt participants)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	—	Y
Saajanaho et al. (2016)	Finland	Community	205	Y	Y	—	Y	Y	Y	Y	Y	Y	Y	Y	—	Y
Schellinger et al. (2018)	United States	Community	160	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	—	Y
Schulman-Green et al. (2006)	United States	Community	142	Y	Y	Y	Y	—	Y	Y	Y	Y	Y	Y	—	Y
van Seben et al. (2019)	The Netherlands	Rehab and community	10	Y	Y	—	Y	—	—	Y	Y	—	Y	Y	—	—

Note. OP = outpatient; pt = patient; Y = meets quality criteria; — = does not meet criteria; ↓ = low meets some but not all criteria.

All papers stated a clear purpose and methodology appropriate to address the aims of the study. Trustworthiness in the papers was assessed by four domains: credibility, dependability, transferability, and confirmability (Connelly, 2016) and these varied (see Table 1). Credibility was assessed by the presence of literature reviews, explicit methodology, use of patient quotes to describe the phenomena under investigation, and data analysis methods using triangulation, member checking, or third-party involvement. Dependability assessed the consistency and clarity of methods and results to enable other researchers to repeat the study by the same methods. This was consistently high for all papers. Transferability assessed the application of the study findings to other populations and contexts. While the papers were discrete in their populations, settings, and countries which render the transferability low, the findings are generalizable when synthesized in a common topic, hence this review. Confirmability assessed the level of bias in the research. This was high for the majority of papers, otherwise moderate (Hjelle et al., 2016; van Seben et al., 2019) where the relationship between the researcher and participants was unclear.

Synthesis

Two key themes emerged from the data—enablers and barriers to goal setting with older adults. Enablers were either intrinsic (generated by the older adult, from within) or extrinsic (generated by others, such as family or the HCP). Barriers focused on difficulties with goals experienced by older adults. Similarly, two subthemes emerged: The first theme entailed barriers generated by the older adults’ own feelings, thoughts, or behaviors (participant barriers); the second theme entailed barriers that the older person experienced as a patient in the health system (system barriers). Direct quotes from selected studies are provided to exemplify each idea of relevance within the themes.

Enablers

The subthemes of intrinsic and extrinsic enablers are described below.

Intrinsic Enablers

Participants reported they planned goals to enhance their engagement and motivation (Brown et al., 2014; Gorawara-Bhat et al., 2008; Hjelle et al., 2016; Huang et al., 2005; Melville et al., 2002; Pikkarainen et al., 2018; Saajanaho et al., 2016):

If you have something definite in mind, you’ll work harder. (Melville et al., 2002, p. 656)

Participants described the importance of having an internal locus of control as essential for self-reliance and improved well-being (Brown et al., 2014; Coylewright et al., 2016; Gorawara-Bhat et al., 2008; Hjelle et al., 2016; Pikkarainen et al., 2018; Rose et al., 2019; Saajanaho et al., 2016; Schulman-Green et al., 2006):

I am the one who understand the most about what I need to do. It should definitely be me who sets the goals. (Rose et al., 2019, p. 569)

Participants noted an essential component of maintaining their locus of control was the ability to foresee a “future self.” This involved identifying future desires and wishes in addition to the immediate physiological or functional needs:

I wanted to be independent as soon as possible and I worked on that from the start . . . It was difficult but now I can do it again. (van Seben et al., 2019, p. 132)

Participants with this sense of hope were engaged in the goal process, even when the future was not tangible (Brown et al., 2014; Coylewright et al., 2016; Efraimsson et al., 2006; Kuluski et al., 2013; Pikkarainen et al., 2018; Saajanaho et al., 2016):

I love to dance; I just want to dance a few more dances. (Coylewright et al., 2016, p. 1040)

Participants also wanted the autonomy to decide their own goals (Brown et al., 2014; Coylewright et al., 2016; Efraimsson et al., 2006; Feder et al., 2019; Hjelle et al., 2016; Huang et al., 2005; Kuluski et al., 2013; Melville et al., 2002; Pikkarainen et al., 2018; Rose et al., 2019; Saajanaho et al., 2016; Schulman-Green et al., 2006; van Seben et al., 2019):

It is the freedom to decide yourself when you want to go for a walk. (Hjelle et al., 2016, p. 1586)

It was essential for the older adults to have the autonomy to choose their own goals, on their own terms. This included holistic goals (Feder et al., 2019; Hjelle et al., 2016; Huang et al., 2005; Schellinger et al., 2018; van Seben et al., 2019) and a return to “normal” (Gorawara-Bhat et al., 2008; Kuluski et al., 2013; Melville et al., 2002; Pikkarainen et al., 2018; Schellinger et al., 2018; Schulman-Green et al., 2006).

I’ve got to either get somebody in here to stay, to live with me, or go to a care facility. And I prefer to stay here and get somebody to come in. End of story. (Kuluski et al., 2013, p. 6)

Self-confidence was associated with perceived well-being and identity (Pikkarainen et al., 2018):

I have found the real me, my inner me, which I had lost during these past decades. (Pikkarainen et al., 2018, p. 6)

Self-confidence also aligned to perceived independence with self-care (Efraimsson et al., 2006; Feder et al., 2019; Gorawara-Bhat et al., 2008; Melville et al., 2002; Saajanaho et al., 2016; Schulman-Green et al., 2006; van Seben et al., 2019).

I don’t know if I will ever be able to take care of myself, if I can go back home or where I will stay. (Efraimsson et al., 2006, p. 72)

Participants noted it was important to celebrate the small gains—

minor things that got me going (Brown et al., 2014, p. 1024)

—in addition to the overall big picture (Brown et al., 2014; Feder et al., 2019; Hjelle et al., 2016; Melville et al., 2002; Pikkarainen et al., 2018; Rose et al., 2019; Saajanaho et al., 2016; Schellinger et al., 2018; Schulman-Green et al., 2006):

I want to stay alive. (Schellinger et al., 2018, p. 163)

Likewise, participants sense of control was stronger if they felt they were taken seriously by the staff members (Brown et al., 2014; Coylewright et al., 2016; Efraimsson et al., 2006; Hjelle et al., 2016; Huang et al., 2005; Kuluski et al., 2013; Melville et al., 2002; Pikkarainen et al., 2018; Rose et al., 2019; Saajanaho et al., 2016; Schulman-Green et al., 2006).

At least I knew what was going on and how they are going to help me, then I knew what I wanted to do. (Rose et al., 2019, p. 570)

Extrinsic Enablers

Participants reported support for goal setting from HCP, family, and friends (Brown et al., 2014; Efraimsson et al., 2006; Feder et al., 2019; Gorawara-Bhat et al., 2008; Hjelle et al., 2016; Huang et al., 2005; Melville et al., 2002; Pikkarainen et al., 2018; Rose et al., 2019; Schellinger et al., 2018; Schulman-Green et al., 2006):

I need emotional support to deal with my illness and other concerns. (Schellinger et al., 2018, p. 162)

This was particularly so when staff members were well informed about the participant’s health condition, prognosis, and treatment options:

[The facilitator] wanted to know more in detail how does that affect you and what would you like to change. (Feder et al., 2019, p. 5)

Participants’ self-belief influenced their level of confidence in, trust of, and reliance on staff members. Participants’ motivation to participate in activities was related to their functional status (Brown et al., 2014; Efraimsson et al., 2006; Feder et al., 2019; Gorawara-Bhat et al., 2008; Hjelle et al., 2016; Huang et al., 2005; Melville et al., 2002; Pikkarainen et al., 2018; Rose et al., 2019; Schellinger et al., 2018; Schulman-Green et al., 2006):

In the early stage of the reablement, the professionals walked next to me up the stairs, I did not trust myself. I regained some confidence after intensive training, and they walked behind me. (Hjelle et al., 2016, p. 1586)

Shared language enabled shared decision-making (Brown et al., 2014; Coylewright et al., 2016; Efraimsson et al., 2006; Hjelle et al., 2016; Huang et al., 2005; Melville et al., 2002; Pikkarainen et al., 2018; Rose et al., 2019; Schulman-Green et al., 2006):

I wrote a list beforehand of what I wanted to talk about in the meeting and my ideas on my goals. (Rose et al., 2019, p. 570)

Likewise, staff members who used a coaching approach to revisit goals were seen to be flexible with identifying and managing complications (Brown et al., 2014; Coylewright et al., 2016; Huang et al., 2005; Kuluski et al., 2013; Pikkarainen et al., 2018; Rose et al., 2019; Schellinger et al., 2018). This incorporated future planning, including support strategies, such as arranging discharge services to reduce the carer burden on loved ones, or getting financial affairs in order (Coylewright et al., 2016; Huang et al., 2005; Kuluski et al., 2013; Pikkarainen et al., 2018; Schellinger et al., 2018).

Protect my assets and get my affairs in order to leave some money for my family. (Schellinger et al., 2018, p. 161)

Participants felt uncertain about the future due to fluctuations in their physical or emotional status and needed HCPs to be flexible with goal activities. Participants also identified that staff input was necessary to reevaluate or redefine goals when they were making slower progress than expected, or at times of transition or discharge:

. . .move to a place where there are increasing levels of care. (Kuluski et al., 2013, p. 162)

In addition to the intrinsic and extrinsic enablers, participants identified barriers to goal activities.

Barriers

The subthemes of participant and system barriers are described below.

Participant barriers

Participants reported difficulties with setting and working toward goals when they felt under pressure (Brown et al., 2014; Coylewright et al., 2016; Rose et al., 2019):

If you place too many goals on yourself, I think you can stress yourself out in the process. (Brown et al., 2014, p. 1023)

Difficulties were also identified when participants recognized challenges with their own communication or ability to think clearly:

I did not really follow what they were talking about. (Coylewright et al., 2016, p. 72).

Participants identified a major barrier to goal pursuit when experiencing pain, or from feeling fatigued:

. . . but (I was) exhausted, exhausted, so exhausted and . . . weak and . . . tired . . . (Coylewright et al., 2016, p. 72)

In addition to affecting physical energy, fatigue also reduced emotional capacity:

I pushed back a lot of doctors because I was on overload. I could not cope with it all. (Feder et al., 2019, p. 4)

Fatigue affected participants’ ability to take on new information which affected their engagement with goal processes (Brown et al., 2014; Efraimsson et al., 2006; Feder et al., 2019; Gorawara-Bhat et al., 2008):

Right now, I don’t have control over my life. (Gorawara-Bhat et al., 2008, p. 412)

This feeling of lack of control affected thoughts, feelings, and expectations:

But you can’t be [homesick] when you can’t manage yourself, you know (Efraimsson et al., 2006, p. 71)

Participants articulated their dismay when goals were not attainable, or not achievable in the timeframe expected:

My body has failed me, I cannot help myself anymore and I can’t do things I enjoy. (Efraimsson et al., 2006, p. 73)

Other emotional barriers to goal activity were generated by the unpredictability of the health event that had led to the admission:

I feel as if the future is uncertain and I don’t know how life will end up. Am I going to be better or remain disabled and in that case how severely? (Efraimsson et al., 2006, p. 72)

Uncertainty was heightened by the acuity of the condition, particularly when they were in shock and their primary concern was surviving, not setting goals:

Goal planning really wasn’t a high priority, I was just doing the best that I could. (Brown et al., 2014, p. 1023)

Regardless of the study setting, some participants identified a helplessness that was closely linked to a lack of knowledge about diagnosis, progress, or discharge plans. Participants relied on the HCP for medical stability, symptom relief, or next steps:

Some days it feels like it doesn’t matter. My life is about to end anyway. They can do whatever they want with me. (Efraimsson et al., 2006, p. 72)

Other participants described a fear of the unknown, including a potential change in future roles or of becoming totally reliant on family or loved ones (Gorawara-Bhat et al., 2008; Huang et al., 2005; Kuluski et al., 2013; Schellinger et al., 2018):

become a burden to my sons. (Huang et al., 2005, p. 309)

Increased stress levels were a barrier to articulating clearly and acting on goals:

. . . I could go blind . . . I could have an amputee . . . like, my sister had diabetes. She had [to have] her legs amputated . . . So I know those things can happen [to me]. (Gorawara-Bhat et al., 2008, p. 413)

System barriers

In addition to the barriers they identified in themselves, participants also identified barriers within the setting. Limited time for goal discussion created pressure for themselves . . .

I do not hurry, it is not good for elderly people, we do not like to rush. (Hjelle et al., 2016, p. 1585)

. . . as well as pressure on the HCP:

They don’t have enough time to talk to us. Always the consultations are very brief. (Schulman-Green et al., 2006, p. 148)

Time pressures extended into perceived restrictions with participants’ ability to stay in the service as long as they felt they needed:

I was only allowed to stay very shortly. So I had to leave even though I wanted to improve and regain my previous level of functioning. (van Seben et al., 2019, p. 133)

Participants felt pressured and detached from goals when they had been identified or worded by the staff:

They had a plan to work to and we just plodded our way through it. (Brown et al., 2014, p. 1023)

These goals may not have been discussed with the participant, who felt disempowered by decision-making that was not shared:

It was hard . . . when other people are making decisions that concern yourself. (Efraimsson et al., 2006, p. 72)

They [staff] did not really set goals with me . . . when they turned up, they made the decision about what to do. (Rose et al., 2019, p. 570)

Participants’ lack of familiarity with goal language was a barrier. Even when participants had identified the goal, they did not necessarily understand how to achieve it:

I would have like them to break things down more . . . to help me understand how I could achieve going home and being independent. It is hard to understand what I need to do to achieve this. (Rose et al., 2019, p. 571)

The link between goals and the steps required to achieve them were not always obvious to the participant:

I am not entirely clear on what activities I find difficult . . . I don’t remember us setting my goals and I can’t say that I know what my goals are. (Rose et al., 2019, p. 570)

The unfamiliar goal language was also incongruent with holistic rather than medical- or condition-based goals:

I certainly never talk to a physician about my life goals. I say, “I can’t move my right arm.” He gets the point. But we don’t talk life goals, we talk symptoms. (Schulman-Green et al., 2006, p. 148)

This confusion with the language used around goals by clinicians made the reason for discussions about goals unclear to participants (Efraimsson et al., 2006; Gorawara-Bhat et al., 2008; Hjelle et al., 2016; Rose et al., 2019):

“Why is she (the social worker) asking so much?” and . . . “I am just going home, am I not?,” I thought . . . So I did not really follow what they were talking about. (Efraimsson et al., 2006, p. 74)

Discussion

This review has synthesized studies describing older patients’ experiences of goal setting and attainment in the context of the health system. Despite the universal use of goal setting in health care practice with older adults, and wealth of evidence for patient goals in rehabilitation and community settings, there was no previous synthesis investigating older adults’ perceptions and experiences of goal setting in health care practice.

Goals should provide an opportunity for shared decision-making and person-centered care (Bachmann et al., 2010; Rose et al., 2019) to enhance motivation and engagement and improve self-efficacy (Levack et al., 2016). The qualitative nature of describing experiences resulted in qualitative or mixed methods studies being selected. Personal patient goals were identified through all stages of the health journey from the acute setting, through rehabilitation, and into the community, although the intent of these goals may have influenced the inconsistent language regarding “patient” goals. Terminology was varied in the selected articles and changed between patient goals (Brown et al., 2014; van Seben et al., 2019), health goals (Schulman-Green et al., 2006), care goals (Coylewright et al., 2016; Kuluski et al., 2013; Schellinger et al., 2018), health care goals (Gorawara-Bhat et al., 2008; Huang et al., 2005), health outcome goals (Feder et al., 2019), life goals (Schulman-Green et al., 2006), personal goals (Efraimsson et al., 2006; Hjelle et al., 2016; Saajanaho et al., 2016), rehabilitation goals (Pikkarainen et al., 2018; Rose et al., 2019; van Seben et al., 2019), and tasks (Melville et al., 2002). While these multiple terms were not used collectively with each individual participant, they do reinforce that language may be confusing to the patient and contribute to the inconsistencies felt by older adults in the goal setting process. Using consistent “patient goal” terminology puts the patient at the center of the conversation, supports the patient to articulate what is important to them both now and into the future, avoids confusion with alternate terms that imply different motives, and provides the platform to work collaboratively toward meeting those goals.

Participants unsurprisingly reported feeling less in control and, therefore, less likely to engage with goal processes when their focus was on survival. Engagement with goal processes was also affected throughout the health journey by ongoing fatigue that affected physical and emotional well-being. Engagement was worsened further by uncertainty regarding prognosis or ability to manage independently in the future. These findings align with Cacioppo (Cacioppo & Cacioppo, 2014) who identified a reduction in self-rated health, reduced meaning to life, more dissatisfaction, and a negative expectation for the future when associated with self-preservation. Similarly, when older adults encounter goal challenges, the flexibility of their approach and their ability to adjust correlates with overall life satisfaction (Bailly et al., 2014). In contrast, participants who were more medically stable identified broader, holistic goals. These participants were more likely to engage in activity or leisure goals consistent with preferences and well-being, findings that align with subjective well-being in older adults (Simone & Haas, 2013).

An important finding of this review is that the factors important to the participants were not necessarily important to the HCPs and vice versa. Self-belief was the strongest enabler for patient engagement with goals. To build self-belief and rapport and support goal setting, HCPs can facilitate patient engagement by exploring their hopes and aspirations for the long term as well as in the immediate context of that health care setting. Current tight time pressures for HCPs in the health system are unlikely to ease. Therefore, investing early in understanding each patient will prove more efficient in the long term. A coaching approach will facilitate patient self-determination and their ability to look forward, both of which enhance engagement and participation.

Participants identified the importance of small as well as large gains in working toward their goals. This underpins the importance of HCP proficiency with identifying the stepwise, smaller actions need to attain broader goals. In addition, HCPs need to be flexible with refining and altering these steps when delays, limited progress, or nonattainment occurs. Small, incremental gains may not be reported formally in the medical records by staff, particularly in electronic medical records where automated entries are more time-efficient than detailed content. Alternate methods of acknowledging and recording incremental progress may be required to keep patients motivated and engaged, and HCPs aware of changes.

Limitations

Papers written only in English were selected. The heterogeneity of settings of the included articles identifies the breadth of health systems and services that use goal setting and pursuit with patients. However, this reinforces the challenge of consistent terminology and language during initial goal setting and along the health journey. Transferability across studies was considered low due to the heterogeneity of patient groups, small sample sizes, and settings. This review is limited by no statistical measure of agreement between the reviewers in the title, abstract, or full-text identification stage and by synthesizing the text available in the reviewed papers and not the raw qualitative data from each study. Similarly, the investigation of patients’ perceptions and experiences of their goals was not cross-referenced to simultaneous experiences or perceptions of carers and HCPs. Further research in this area would be beneficial to assist HCPs more effectively to facilitate goal setting activities with patients.

Clinical Messages

Be consistent with “patient goal” terminology and intent

Recognize and accommodate the physical, psychological, and cognitive effects of fatigue to facilitate goal engagement

Support older adults to articulate holistic goals even when they are outside the remit of the current service. Holistic goals can be broken down into smaller actions to enhance engagement, adherence, and person-centered care

Footnotes

Appendix

Appendix.

Medline Search Strategy.

1. *Goals/

2. goal*.tw.

3. 1 or 2

4. aged/ or “aged, 80 and over”/ or frail elderly/

5. ((old* or aged) adj1 (person or people* or adult* or resident* or population* or men* or women* or male* or female*)).tw.

6. (elderly or elder? or geriatric** or gerentol* or retired or retiree* or senior?).ti,ab.

7. 4 or 5 or 6

8. ((patient* or client* or outpatient* or inpatient*) adj3 (perceiv* or perception* or opinion* or voice* or view* or attitude* or thought* or observation* or experience* or belief*)).tw.

9. 3 and 7 and 8

Acknowledgements

Grateful thanks to Nikki May, librarian, for her expertise with the search strategy for this manuscript. The primary author would like to thank her supervisors, the coauthors, for this paper’s contribution to her Master of Clinical Rehabilitation by Research Degree.

Author Contributions

N.B., S.L., S.J.G., and S.G. all contributed to the design and conduct of the systematic review, to data analysis and drafts of the manuscript and have read and approved the final manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: N.B. was supported by Research Training Program (RTP) funding as part of the Master’s Degree.

ORCID iDs

Nicky Baker

Susan J. Gordon

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