Theory-Based Approach to Goal Setting

Background: Goal setting is accepted 'best practice' in stroke rehabilitation in the United Kingdom however; there is no consensus about what the key components of goal setting interventions are or how they should be optimally delivered in practice.

Methods: The Medical Research Council (MRC) framework for developing and evaluating complex interventions guided the development and conduct of a programme of research which included the following studies:

• a review of the literature to identify theories of behaviour change with most potential to inform goal setting practice;

• a causal modelling exercise to map identified theoretical constructs onto a goal setting process and convening of a multi-disciplinary Task Group to develop the theoretical process into a Goal setting and Action Planning (G-AP) practice framework

• a process evaluation of the G-AP framework in one community rehabilitation team and

• a UK wide survey to investigate the nature of services providing community based stroke rehabilitation across the UK and what goal setting practice is in these settings in order to understand the context into which an evaluation of the G-AP framework could be introduced.

Results: The review of the literature identified three theories of behaviour change that offered most potential to inform goal setting practice: Social Cognitive Theory, Health Action Process Approach and Goal Setting Theory. These theories contained constructs directly relevant to the goal setting practice: self-efficacy, outcome expectancies, goal attributes, action planning, coping planning and appraisal and feedback. The causal modelling and Task Group exercise:

• informed development of the G-AP framework into a four stage, cyclical process

• proposed mechanisms of action and

• predicted outcomes G-AP was likely to impact on.

The process evaluation suggested that each stage of the G-AP framework had a distinct purpose and made a useful contribution to the process. Overall, G-AP was acceptable and feasible to use but implementation of novel aspects of the framework was inconsistent and health professionals had concerns about the potential impact of unmet goals on patients' wellbeing. Patient reports suggested that

• the experience of goal non-attainment could facilitate adjustment to limitations resulting from stroke and

• feeling involved in the goal setting process can incorporate both patient-led and professional-led approaches.

The survey findings highlighted the variability that exists in community based stroke rehabilitation services in the UK. Goal setting is reportedly used with all or most stroke survivors in these services; however, practice is variable and may be sub-optimal.

Conclusions: GAP has been explicitly developed to guide health professionals through a systematic, theoretically based and patient centred goal setting process in community based stroke rehabilitation. G-AP is a cyclical process that that has four key stages, proposed mechanisms of action and has shown promise as an acceptable, feasible and clinically useful framework to guide goal setting practice. The complexity that exists within community based stroke rehabilitation services, and the variability in usual goal setting practice used within them, should be considered when designing a study to evaluate the effectiveness of G-AP in routine practice.