How to Write Fluency Based Goals in OT. It’s easier than you think!

Goal writing is tricky and not so easy for many of us OTs.  It truly can feel daunting. If you are anything like me… you probably spend too much time editing, finessing, pondering and fussing over goals. But for good reason.

After all, OT goals are the GPS of our interventions.  When written well goals can help us navigate the treatment plan and lead us to better outcomes.  What I realized later on is that adding the element of fluency into our goals, actually supercharges the goal offering us tons of advantages.

The problem with traditional OT goals

The first step to writing goals is functionality.   We as OTs start by asking ourselves how to teach a client skill X,Y & Z so the client can be functional and independent in everyday life.  We typically do not consider fluency or mastery of the skill (in the true sense at least).  

However, it is important to note that when we just focus on teaching the skill without fluency, we risk the chance of needing to reteach the skill at some point.  What we end up doing is teaching the skill just for that ‘moment in time’ which may or may not continue to generalize in the long term.  Just because an individual can perform a skill on 2 of 3 occasions, it does not necessarily indicate mastery of fluency in this skill.  It does not give us any indication of the longevity of the skill or future performance. 

Consider this… if we teach a client to perform the skill, but it takes them ages to complete it, then the client will be less likely to use it on a day to day basis.   So how useful and functional was teaching that skill after all?  

The solution is fluency.   By adding a time based measure to the goal, i.e. making it more fluency based, it signifies not only that the client will be able to compete skill X not only on 2 of 3 occasions, but they will also perform this skill effortlessly, without hesitation, in a smooth coordinated timely manner in the future.  

So if you think about it, SMART OT goals can actually be SMARTer,  if we write them with mastery/ fluency in mind. 

Let’s take a look at how we may write a very common shoe tying goal in OT….

By his next Annual review, Peter will demonstrate increased participation in the school setting by tying his shoelaces independently using the single loop method with 100% accuracy on 2 of 3 trials.

The way this goal is written suggests that as long as Peter can tie his shoe laces on 2 of 3 opportunities, regardless of how long it takes, then he has met the goal.  Since fluency is not a consideration in this goal, Peter can take as long as he likes.  However, the psychology of human behavior suggests that if something takes too long, we are less likely to do it, therefore less likely to practice it and less likely it will lead to the goal of independence and generalization.

Nonetheless as far as SMART goals goes, this looks like a fairly well written goal.  Let’s take a closer look …

Undoubtedly measurement is often the trickiest part of goal writing in OT.  While the traditional measurement criteria, i.e. on 2 of 3 opportunities/ trials has become somewhat of a standard commonplace for goals in OT, and it is measurable.  It brings up several unanswered questions and assumptions i.e….

1. Does this criteria mean that the skill is mastered and the client can do it just as well as his peers ?

2. Can we assume the client will be 100% independent with this skill from this point forward?

3. Can we assume this skill will not need to be taught again?

4. Does it mean that the client is efficient (timely) with this skill or does he/ she take a long time to complete it?

I myself have pondered these questions many times in my practice.  On many occasions I saw that although my student met the goal and ‘knows’ how to perform the skill independently, he would not using it outside of our OT sessions.  I soon realized that since he had not truly mastered the skill and he did not feel confident using it in any other setting, therefore generalization was not occurring.  I also realized that sometimes I would have to re- teach the skill even though ‘technically’ the goal was met.  I knew something was amiss.

However, once I started reading the research on the effects of fluency-based instruction, I realized this was the missing link.  This a great read it you want to review some of the research on using the science of Fluency by an educator called Ramirez in 2011.

The Effects of Fluency-Based Instruction on Skill Acquisition in Children Diagnosed with Landau Kleffner Syndrome.)

This is one of the many articles that changed my perspective and the reason why I started adding fluency to my goals.  I soon discovered that not only did my students meet their goals faster, they mastered the skill which led to greater confidence.  I also realized that my students wanted to ‘show off ‘ to their skills to everyone.  So, adding fluency became reinforcing for both of us.

Needless to say I was hooked.   That’s how fluency based goals became my go to.

Circling back to Peter…

From a mastery/ fluency standpoint, let’s discuss what we actually want for Peter?  Of course we want him to is to tie his shoes independently and accurately, but we also want him to do this in an appropriate time frame as compared to his peers.   

So the first thing we need to do is figure out a fluency goal or aim for Peter.  We can do this by trying to find how long it takes (duration) to perform the skill from beginning to end or we can determine a count/minute goal ( i.e. how many times can the average person tie their shoes in 1 minute with accuracy? )  I prefer to do the latter as it makes data collection super quick and easy (it just takes 1 minute) and it adds a ‘fun’ element to data collection, where it feels more like you are playing a game.

So what we need to ask ourselves is…

How many times can you complete this skill with accuracy and fluency in 1 minute?

Go ahead, set your timer and give it a go.

Using ourselves as a guide, we can infer that to be fluent in the skill of shoe tying, Peter should be able to his shoes approximately 7 times in 1 minute. 

This could be used as the fluency goal or we can choose to be a little more conservative depending our clinical judgement.  I tend to err on the side of caution and use a range for my fluency aim whenever possible.  The fluency aim should serve as general guide as we always need to consider client factors and possible limitations of our clients.   

Of course, it would be helpful to have another student Peter’s age perform this task to get a more accurate fluency goal, but that is not always possible.  

Since Peter is a child, I chose to lower the fluency aim and decided on a goal of at least 4 correct responses/ minute.  Now this is my minimum  requirement, but of course I will always encourage Peter to complete as many correct responses as possible.

Now that we know the fluency aim, we can simply insert it to the original goal to make it a Fluency- based goal.

By his next Annual review, Peter will demonstrate increased participation in the school setting by tying his shoelaces independently using the single loop method on 4 of 5 trials in a 1 minute timing.

What about the Objectives/ Benchmarks?

Now that we have a fluency based goal, we need to write fluency based objectives to meet that goal.   All we need to do is apply the same criteria to  the objectives.  For example:

Objective #1 Peter will complete steps 1 & 2 of shoe tying ( Pulling up lace tightly and completing first knot) on 4 of 5 trials in a 1 minute timing independently.

Objective #2 Peter will complete steps 1 – 4 steps of shoe tying (Pulling up lace tightly, completing the first knot, making a loop, holding it with one hand and wrapping other shoelace around loop once) on 4 of 5 trials in a 1 minute timing independently.

Objective #3 Peter will complete steps all six steps of shoe tying (Pulling up laces tightly, completing the first knot, making a loop, holding it with one hand and wrapping other shoelace around loop once, poking wrapped shoe lace through, grasping with other hand and pulling shoelaces tight.) on 4 of 5 trials in a 1 minute timing independently.

Keep in mind in this example, Peter is a fairly typically developing client.  However, when have clients who have underlying limitations,  we may need to consider more than fluency in the component skills required for shoe tying:  i.e. visual motor skills, pinch strength, sequencing skills, motor skills etc.  Practicing the steps of shoe- tying without fluency in the component skills, would be counterproductive to say the least.

Want to know what underlying skills are required for shoe-tying?  Below is a fluency based treatment plan specifically for shoe tying to help OTs address these underlying skills.  The worksheet includes a list of all the component skills required for shoe tying with approximate fluency aims and an activity analysis of shoe tying to help create goals/ objectives.

You can download this resource with a PREMIUM Membership!

Conclusion

I used this shoe tying fluency based goal in the school setting last year and I can tell you from first hand experience, that my student met his goal much faster than expected (within weeks), so be prepared as you may not need the entire school year to teach this skill.  That’s the power of fluency!

Also, remember, adding fluency, does not mean that you to change the format of your sessions and just do repetitive timings all the time.  All I did is at the end of every session, I did five 1 minute timings and took data. This took all of 5 minutes out of the session.

My student was always so excited to participate in what I called the ‘minute to win it game’ of shoe tying.  Not only did he have fun ‘competing’ with himself, he was so motivated to work on this task while I monitored progress/ took data….. all in a matter of minutes!

In my experience, fluency based goals really do make OT SMART goals SMARTer.

To recap, here are the steps for switching your OT goals to fluency based goals:

1. Start with a traditional OT SMART goal.
2. Find the fluency aim by timing yourself or a peer performing the skill for 1 minute.
3. Determine the # of correct responses in a 1 minute.
4. Add this range as the fluency criteria to your goal.

If you do actually give it a go……please do let me know in the comments below.

Plus, I am curious…. How fluent are you at tying your shoes?

References

Ramirez, M. (2011). The Effects of Fluency-Based Instruction on Skill Acquisition in Children Diagnosed with Landau Kleffner Syndrome (Doctoral dissertation, Duquesne University). Retrieved from https://dsc.duq.edu/etd/1083