As a field, SLPs don’t tend to write true participation-level speech therapy goals (Baylor & Darling-White, 2020). Our field is still transitioning from a medical model to a client-centered, participation-focused model of service delivery. If this is you, you’re not alone! Hundreds of EST readers have reported that they struggle to find and write meaningful goals in one of my surveys. As a group, we tend to write skill- or activity-based goals and “tack on” a participation element. In this tutorial, we’ll learn how to assess participation using visual analog scales and turn that baseline into a true participation level goal using the SMART goal format.
Free DIRECT download: Guide to VAS for participation goals (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- What is a participation-level goal?
- Why should we write participation-level goals?
- How can we measure participation?
- What are self-anchored rating scales?
- Visual analog scale (VAS).
- VAS tutorial in 5 steps.
- A quick word about practicalities.
- Tell us about a time you used VAS.
- Learn more.
- Related Eat, Speak, & Think posts.
- References.
What is a participation-level goal?
If you know your ICF model from the WHO, you know that its goal is to focus our understanding and treatment of health-related conditions on the impact it has on a person’s life. In other words, we’re supposed to provide person-centered care in a way that has a meaningful impact on our patients’ lives. (ICF, WHO 2002)
Speech therapy as a field has not yet achieved this ideal.
Speech-language pathology services in many settings still lean heavily toward a medical model of service delivery, focusing largely on addressing physical impairment and injury… and how those impairments impact the individual’s performance of communication tasks.
Baylor & Darling-White, 2020, p. 1336
We are still in the process of moving the field of speech therapy from a medical model to a true person-centered model. Many of us are writing goals that we think are participation-based, but are actually only signaling an intention or hope that our therapy will improve participation-level activity.
This is a common type of goal that does not actually target participation, according to Baylor & Darling-White (2020):
Client will demonstrate speech intelligibility of 90% or higher at the end of 8 weeks to facilitate participation in knitting club.
Baylor & Darling-White, 2020, p. 1341
The authors point out that the client can achieve this goal without improving their participation in knitting club. There may be other factors limiting the client’s performance in knitting club, such as:
- Client may feel self-conscious about their changed speech and not speak up.
- Other members of the knitting club by react negatively to the client.
- Perhaps there is background noise that presents a barrier for the client to be heard.
Here is a participation-level goal:
Client will report a level of satisfaction with participation in conversations at knitting club as 80 or higher on a 100 mm VAS by the end of 8 weeks.
Baylor & Darling-White, 2020, p. 1341
I don’t know about you, but my mind was blown when I read the above goal! This goal is targeting the patient’s own reported level of satisfaction in a communicative context that matters to them. You can’t get more person-centered than that, right? To be honest, I didn’t even know we could write goals like this before reading this paper.
Why should we write participation-level goals?
If you read the two example goals above, I bet it’s clear why we should write true participation-level goals:
- Ensures that we’re targeting a goal that is meaningful to the patient.
- Makes it easy to keep therapy activities and materials focused on the goal.
- We can give personalized strategies our patients can implement in a real-world situation.
- Patients are more motivated by seeing the results of their efforts.
- Demonstrates our value to patients, families, the medical team, employers, and payors.
How can we measure participation?
According to Baylor & Darling-White (2020), our primary assessment tool for the participation level should be a patient-reported outcome measure (PROM), whether it’s a published one or one we make with our patient.
Baylor & Darling-White point out two potential problems with published PROMs. First, the PROM may not measure the participation level. Second, even if we find a participation-based PROM, it may not be sensitive enough to capture the improvement we’re expecting.
Fortunately, we have access to valid assessment tools in the form of self-anchored rating scales (SARS) and goal attainment scaling (GAS). These tools offer person-centered assessment tools that serve as their own outcome measures.
- Self-anchored rating scales (SARS).
- Visual analog scales (VAS).
- Likert scales.
- Goal attainment scaling (GAS).
VAS, Likert scales, and GAS are easy to use in collaboration with patients and family, and allow us to personalize therapy in a meaningful way. I wrote a GAS tutorial recently; read on to learn about SARS.
What are self-anchored rating scales?
Self-anchored rating scales (SARS) are valid, non-standardized assessment tools that allow for patient-centered assessment and measurement of outcomes. “Self-anchored” simply means our patient defines what the endpoints mean. SARS are personalized scales that are sensitive to the changes we hope to see with speech therapy.
SARS are useful when our patient wants to improve in terms of satisfaction, confidence, feeling competent, etc. There are two kinds of SARS: visual analog scales (VAS) and Likert scales. We can measure how our patient feels using either a Likert scale or VAS, whichever resonates better with our patient.
We can use Likert scales and VAS to target any domain of the ICF model (participation, skills, environment, and personal factors). This tutorial is focusing on using VAS to assess the participation level of the ICF. VAS could measure positive emotions or attitudes such as level of satisfaction or confidence. Or the VAS could measure negative emotions or attitudes such as nervousness or frustration.
If our patient wants to use a different measure of participation, such as # of times volunteering a comment during a support group meeting, then we can use GAS. As a reminder, GAS can be a subjective, interview-based PROM or a personalized, performance-based objective measure. I recently wrote a tutorial on GAS and SMART goals.
Before I move on to VAS, just a quick word on Likert scales. Likert scales are typically expressed on a scale of 1 to 5, 1 to 7, or 1 to 10. The patient defines the end-points. Here is an example of a SMART goal using a Likert scale. This particular goal is targeting personal factors (rather than participation):
Client will report experiencing a level of nervousness about communicating in social interactions in work settings as a 3 or lower (scale of 0-10; 0 = not at all nervous, 10 = very nervous) by the end of 6 weeks.
Baylor & Darling-White, 2020, p. 1354
Visual analog scale (VAS)
A visual analog scale (VAS) is a 100 mm line in which the user ticks off where they feel they stand. If you’ve used the CAPE-V in voice assessment, then you’ve already used a visual-analog scale.
Here is an example of how to write a SMART goal using the CAPE-V as an assessment tool. This goal is targeting the “skills” domain of the ICF.
Client will demonstrate all aspects of voice quality at an SLP-judged rating of 15 or lower on the CAPE-V protocol by the end of 12 weeks.
Baylor & Darling-White, 2020, p. 1353
VAS tutorial in 5 steps
We can write and use visual analog scales (VAS) in 5 simple steps, in collaboration with our patient and/or their family.
- Identify a single participation-level situation.
- Patient defines the endpoints and ticks off where they stand.
- Turn the VAS into a SMART goal.
- Use the VAS as a brainstorming or teaching tool (optional).
- Reassess with the VAS.
Identifying a single participation-level situation is just one part of Baylor & Darling-White’s 2020 model of communicative participation intervention. I strongly encourage everyone read that paper for an excellent tutorial on how to achieve participation-focused therapy. They offer many examples and supporting materials.
1. Identify a single participation-level situation
First, we start off by collaborating with our patient and/or their family to identify a single participation-level situation that they would like to improve. For speech therapy, it would need to be related to communication (voice, speech, language, or cognitive-communication) or swallowing.
This is probably the hardest step.
Sometimes we get lucky and our patient knows exactly what they want to get out of speech therapy. But often, patients tell us that they want to be able to talk normally or have a good memory. Goals written with those wishes in mind are likely going to be broad and generic.
Here are some ideas for how to identify a single situation to target in therapy. This is just a sampling of possibilities.
- Motivational interviewing:
- What is your most important conversation?
- “Miracle Question”: If you woke up tomorrow and this was no longer a problem for you, what would you notice was different? What would your family notice was different? (Franklin et al., 1997).
- Show a checklist to jog ideas, such as:
- Aphasia Needs Assessment (Garrett & Beukelman, 2006).
- EST’s list of 54 skills and activities.
- Use a PROM to generate ideas, such as:
- Communicative Participation Item Bank (Baylor et al., 2013)
- Memory Mistakes – Multifactorial Memory Questionnaire (Troyer & Rich, 2002)
- Neuro-QoL Cognitive Function Short Form (2nd part).
- Life Interests and Values Cards (Haley et al., 2013).
If you use a PROM to brainstorm situations, you’ll probably still want to write a self-anchored VAS. As stated above, not all PROMs measure participation. Even if the PROM you use does measure participation, it may be too broad to capture the change you expect to see in therapy. (Baylor & Darling-White, 2020, p. 1340)
If your PROM meets your needs, you can jump to step 3, in which you’ll write a SMART goal based on the PROM. Otherwise, you can go to step 2 to create your personalized VAS.
Let’s create an example patient, Isabel. Isabel is a 67 year old widow who has mild anomia following a stroke, which causes her a lot of social anxiety. She goes to an aphasia support group, but she rarely speaks because she doesn’t want to “sound like an idiot.” Isabel would like to feel more comfortable speaking up in her support group.
2. Patient defines the endpoints and marks their starting point
Once we have a single participation-level situation to target in speech therapy, we’ll need to measure our patient’s baseline with VAS (or a Likert scale or with GAS).
The first step is to have our patient define the parameter they want to measure themselves against. Here are some possibilities (but we’re not limited to these), from Baylor & Darling-White (2020):
- Level of satisfaction.
- Feeling left out.
- Feeling isolated.
- Being a bystander in conversations.
- Comfort level.
- Level of nervousness.
- Level of frustration.
Next, label the endpoints of a 100 mm line, using the parameter that resonates with our patient. Examples of endpoints, just to give you an idea:
- Not at all satisfied – Very satisfied.
- Feel completely left out – Feel not at all left out.
- Feel very isolated – Feel not at all isolated.
- Very nervous – Not at all nervous.
Finally, we ask our patient to put a line through where they feel they are currently. We measure how many millimeters from the left edge their tick mark is, and that is their score out of 100.
Isabel, our example patient, has chosen her endpoints: “Not at all comfortable – Very comfortable.” For her baseline, she has ticked off at 34 mm as measured from the left edge. We could write her baseline score like this:
Isabel reports that her feeling of comfort for speaking during her aphasia support group meetings is 34/100 on a VAS scale, where 0 mm = not at all comfortable and 100 mm = very comfortable.
3. Turn the VAS into a SMART goal
By this point, our patient has identified a specific participation-level situation they want to improve, and we’ve gotten a measure of their baseline participation in terms of their attitude, feelings, or emotions. The next step is to write a participation goal in terms of the VAS the patient just completed.
To write a SMART goal, we have to identify the target outcome that is reasonable for the time frame we have for therapy. We should do this in collaboration with our patient. There are two possible options that I can see. I like the first option better.
- After the patient marks their baseline level, have them mark where they would like to be after 4 weeks of therapy (or whatever your time frame is).
- Once you’ve measured their baseline mark, you could tell them their numerical score and then have them tell you what their target is.
Let’s suppose that we followed the first option. After Isabel marked her baseline (34 mm), we asked her to mark where she wanted to be in 4 weeks. Once we measured that tick, we saw that she chose 77/100 mm. Our SMART goal could then be written as:
Isabel will report improved comfort with speaking in her aphasia support group from her baseline of 34 mm to 77 mm on a 100 mm VAS (0 = not at all comfortable, 100 = very comfortable) in 4 weeks.
4. VAS as a therapy tool (optional)
You can use your personalized VAS as therapy tool, if you’d like. Specifically, you could use it as a brainstorming tool or a teaching tool.
Since our goal is to teach our patient how to problem-solve (and therefore generalize from our target situation to other situations), we can use their VAS to help them learn how to brainstorm.
For instance, we could show Isabel her original VAS and pencil in a line at roughly the 50% mark. We could ask her, what are some things you could do this week to help you get here?
You probably have your own ideas of what Isabel could do to feel more comfortable at taking in aphasia group, but giving space for Isabel to reflect can be very powerful. We’d validate anything she came up with, but we could also make suggestions.
While we’re not likely to go with Isabel to her aphasia support group meeting, we can work on supporting skills, strategies, etc in therapy. Indeed, Baylor & Darling-White (2020) suggest we write a goal for each of the other domains of the ICF: skill/activity, personal or social environment, and personal factors.
So, once we use the VAS as a brainstorming tool, we can help Isabel learn a strategy or technique that she can implement at her next aphasia support group meeting.
5. Reassess with the same VAS
Finally, it’s important to remember to reassess with the VAS for our 30 day reassessments and discharge. We should use the same endpoints, and I’d imagine we’d always want to use a new 100 mm line so our patient couldn’t see where they marked before.
When reporting the outcome of the participation level goal using the VAS, we are reporting a valid individualized, person-centered, patient-reported outcome measure of a life participation situation that is meaningful to our patient.
I’m sure that Isabel did amazingly well with our therapy, so this might be our discharge assessment:
GOAL MET. Isabel improved her comfort with speaking in her aphasia support group from her baseline of 34 mm to 85 mm on a 100 mm VAS (0 = not at all comfortable, 100 = very comfortable) by 4 weeks.
A quick word about practicalities
There is no rule that we have to figure this all out in our first session with our patient. In my experience, it’s well worth the time and effort to find a specific, concrete thing that my patient wants to accomplish in therapy. I try to establish this in the first session and obtain a measure to support my clinical judgement that therapy is indicated. I’ve never had pushback for writing a goal to finish the initial assessment at the next visit.
I don’t see any reason why we can’t write a goal such as the following:
Patient will assist in developing a personally-meaningful goal to improve their participation in a specific to-be-determined context, with the new goal to be established within 2 weeks.
You could probably come up with better wording! While we would hope to meet this goal at the next session, this gives us 2 weeks to brainstorm with our patient, get their baseline self-rating, and write the new SMART goal.
Alternatively, we could choose to develop one or more ideas to bring with us to the second session and see if any of them resonate with the patient. This may work well if we have a good idea of what the patient wants, or it may be necessary due to time constraints.
Another consideration is that we may choose to write more than one participation level goal for the same situation. For instance, for Isabel, we could also write GAS for the number of times she speaks up in her aphasia support group meetings. This would give us two ways to show improvement: her feeling of confidence and how often she is actually speaking.
The final point I’d like to make is that we can choose to work on more than one participation level situation at a time or sequentially. Baylor & Darling-White (2020) suggest we work on one situation at a time, but no more than a few.
Tell us about a time you used VAS
Have you used VAS yet? If so, tell us how it went in the comments below. Do you have a tip you can share? If not, try VAS with a patient this week. We’d love to hear how it goes!
Learn more
If you’d like to learn more about self-anchored rating scales, GAS, and Baylor & Darling-White’s model of communicative participation intervention, please check out:
- What Really Happens When Patients Go Home – my recorded 2-hour CE course through MSCC (not an affiliate).
- Baylor & Darling-White (2020) – tutorial, templates, guide, and many examples.
- Bard-Pondarré et al. (2023) – tutorial on GAS, templates and examples.
- Logan et al. (2024) and Logan (2020) – tutorial on GAS, templates, examples, patient materials, videos
Related Eat, Speak, & Think posts
- 35+ free cognitive tests, screeners, and questionnaires.
- Write better cognitive goals with 54 daily activities.
- Learn how Goal Attainment Scaling can make SMART goals better.
References
- Bard-Pondarré, R., Villepinte, C., Roumenoff, F., Lebrault, H., Bonnyaud, C., Pradeau, C., Bensmail, D., Isner-Horobeti, M.-E., & Krasny-Pacini, A. (2023). Goal Attainment Scaling in rehabilitation: An educational review providing a comprehensive didactical tool box for implementing Goal Attainment Scaling. Journal of Rehabilitation Medicine, 55, jrm6498. https://doi.org/10.2340/jrm.v55.6498
- Baylor, C., & Darling-White, M. (2020). Achieving Participation-Focused Intervention Through Shared Decision Making: Proposal of an Age- and Disorder-Generic Framework. American Journal of Speech-Language Pathology, 29(3), 1335–1360. https://doi.org/10.1044/2020_AJSLP-19-00043
- Logan, B. (2020) A practical guide to administering Goal Attainment Scaling. Brisbane: University of Queensland: Centre for Health Services Research – Australian Frailty Network, 2023. https://www.afn.org.au/for-researchers/gas/
- Logan, B., Viecelli, A. K., Pascoe, E. M., Pimm, B., Hickey, L. E., Johnson, D. W., & Hubbard, R. E. (2024). Training healthcare professionals to administer Goal Attainment Scaling as an outcome measure. Journal of Patient-Reported Outcomes, 8(1), 22. https://doi.org/10.1186/s41687-024-00704-0
- Wade D. T. (2009). Goal setting in rehabilitation: an overview of what, why and how. Clinical rehabilitation, 23(4), 291–295. https://doi.org/10.1177/0269215509103551
Free DIRECT download: Guide to VAS for participation goals (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Featured image by Odua Images on Canva.com.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
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