Características de los componentes y recursos en la industria del turismo

As with previous studies (Pound et al, 1995; Tyson and Turner, 1999; Rodgers et al, 2001;

O'Mahoney et al, 1997) patients within the current study do not feel satisfied with the amount of information they received during their rehabilitation and do not feel their questions were

answered. The current study did not explore different methods of information delivery and patient’s satisfaction with the method they received, which would be an area for future research. The current study also did not explore whether patients within this cohort received personalised or general information. Previous studies have identified that personalised information increases patient satisfaction therefore whether the information patients received within the current study may impact upon satisfaction (Hoffman et al, 2007). Currently the information provision after stroke is not standardised therefore it is likely that patients within the current study received a variety of methods and degrees of personalisation. The content is also likely to vary, which

previous studies have shown impacts upon patient satisfaction (Tooth and Hoffman, 2004; Jones et al, 2008; Tyson and Turner, 1994; Maclean, 2000). Topics patients prefer to be included within the information provision include causes of illness, individual progress, risk factors, secondary

prevention and medication (Maclean, 2000; Tooth and Hoffman, 2008; Jones et al, 2008). However the current study did not identify the content of the information patients received therefore can not draw any conclusions regarding content and patient satisfaction with information provision.

One component of information provision is discussion of goals the stroke rehabilitation team are working towards with the patient and providing written information about the goals (Jones et al, 2008). Goal setting is considered to be a central component to the stroke rehabilitation process

(Davis et al, 1992; Partridge and Edwards, 1996) and a process that professionals agree is central to the stroke rehabilitation process (Playford et al, 2009). Stroke rehabilitation patients were least satisfied with goal setting within the current study. They felt goals were not discussed with them and they did not receive written copies of the goals the rehabilitation team were working towards.

Factors impacting upon the provision of goal setting information may be the imprecise conclusion in the literature regarding the most effective method of goal setting, including whether the patient should be present when goals are agreed, the appropriate number of goals and time frame for achieving goals set (Playford et al, 2009; Schut and Stam, 1994). However, Levack et al (2006) identified core mechanisms to be utilised during the process of goal setting, regardless of the outcome measure or approach utilised. All professionals involved in stroke rehabilitation should set goals that are specific and difficult for the patient, include a variety of outcome measures, involve the patient in the process and document that the process has occurred. Utilising these mechanisms can be challenging for professionals which may be impacting upon the

implementation of the goal setting process. For example, conflict can occur between making goals achievable whilst also being ambitious enough to challenge the patient. Specific, difficult goals are more motivating for the patient (Levack et al, 2006) but if the effectiveness of the stroke

rehabilitation service is evaluated on whether the patient achieves their goals, goals are likely to be selected based on being achievable rather than ambitious.

There are also multiple outcome measures available for use in goal setting (Palyford et al, 2006; Wade, 1999; Schut and Stam, 1994) including Goal Attainment Scaling, Functional Independence Measure (Turner-Stokes et al, 1999) and Canadian Occupational Performance Measure (Law et al., 1991). This choice of outcome measures available to professionals may result in confusion over which is the most appropriate to use or excessive time demands upon the professional if all are

used. Either of these factors may result in professionals avoiding the process. There is a lack of empirical evidence to support the effectiveness of these measures and some evidence that casts doubt on the validity of the use of ordinal scales, such as the Goal Attainment Scale (Tennant, 2007). Some objective outcome measures such as the Goal Attainment Scale (GAS) have scientific properties (Hurn et al, 2006) but this objective measure does not necessarily translate into goals that are meaningful to the patient (Worrall et al 2010). Objective measures are less likely to capture the secondary benefits that can occur from patients working towards and achieving their goals. Clinicians may recognise this conflict and the benefit of utilising subjective quality of life outcome measures within goal setting, along with objective measures. However, this will result in increased time demands on professionals to facilitate the completion of multiple outcome

measures. Professionals may recognise that one outcome measure does not necessarily meet the requirements of the goal setting process and therefore not complete any as they can not dedicate sufficient time to complete the process effectively. The availability of staff to utilise time goal setting is key to the success of the process (Playford et al, 2009) and this study has identified that staffing levels are a constraint within stroke rehabilitation. General time demands on staff due to inadequate staffing levels may be limiting staff availability to effectively goal set during stroke rehabilitation.

At a more fundamental level professionals use a wide range of terminology to describe the components of goal setting (Playford, 2009) and that this caused a barrier amongst the clinical team. This range and lack of consensus regarding the process may contribute to the poor delivery of written goals to the patient.

A disparity in what professionals and patient's regard as a suitable level of discussion of goals may contribute to patient satisfaction with the goal setting process (Playford, 2009). It is recognised

that there is a relationship between patient expectations of their treatment and satisfaction (Williams et al, 1995; Hsieh and Donor Kayle, 1991), therefore if the goals were not discussed in the depth that patient's expected, this will lead to dissatisfaction. A patient-centered approach to rehabilitation encourages patient participation in the discussion of their goals, however including patient's in this discussion requires skill from the health care professionals. The discussion needs to be paced at an appropriate rate to facilitate participation of the patient and any communication impairments need to be accommodated. Levels of involvement of the patient also need to be considered and may vary with time since onset of stroke and the individual patient's ability and preference. Levels of involvement can vary from simply witnessing the discussion to leading it, with varying levels in between (Playford et al, 2009). It is therefore important for the healthcare

professionals to explicitly establish the extent to which the patient wishes to be involved prior to starting the goal setting discussion.

Any disparity between the goals patients expect to work towards and those the healthcare

professionals agree may result in dissatisfaction. The current study asked patient's satisfaction with their participation in the discussion of the goals. However, it did not explore satisfaction with the goals decided. Patients' responses to the question in the current study may be influenced by whether they were in agreement with the goals discussed and agreed. Patient's sometimes hold unrealistic expectations from rehabilitation and the process of health care professionals re- phrasing patient goals to make them more achievable can be perceived as 'not listening to the patient's wants' (Playford, 2009). Playford et al (2009) suggested that the goals setting process can be made patient centred by sharing control of the conversation with the patient, developing a shared management plan and developing a shared understanding of the problem. However, even with the implementation of this it is possible for the goal to be quite different to what the patient wanted (Levack et al, 2011). This disparity may result in dissatisfaction for the patient.

Patients with a more recent onset of stroke, within the past six months, were most satisfied with the written goals they received. This may be a reflection of the more recent publication of the standard 'patient's to receive negotiated goals within five days of admission' (NICE, 2010). Stroke rehabilitation teams may have become more aware of this standard and amended the timeliness and provision of written goals to the patients, impacting benefiting who had a more recent stroke.

'Patient motivation' was the second most frequent factor reported by staff to account for the limited recovery patients make after stroke. Previous research has identified that effective goal setting within rehabilitation can increase a patients motivation leading to a behaviour change. Therefore more effective goal setting could not only increase patient satisfaction but also impact upon the recovery they achieve.