The development and initial evaluation of a Goal setting and Action Planning (G-AP) framework for use in community based stroke rehabilitation

Background Goal setting is accepted ‘best practice’ in stroke rehabilitation however, there is no consensus about what the key components of goal setting interventions are, how they should be optimally delivered in practice and how best to involve stroke survivors in the process. This PhD by publication describes the development and initial evaluation of a theory-based goal setting and action planning framework (G-AP) to guide goal setting practice in community based stroke rehabilitation settings. Included studies 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: (i) a review of the literature to identify theories of behaviour change with most potential to inform goal setting practice (Paper 1) (ii) 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 (Paper 2) (iii) a process evaluation of the G-AP framework in one community rehabilitation team (Paper 3) (iv) a United Kingdom (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 (Paper 4) Main Findings 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: (i) Informed development of the G-AP framework into a four stage, cyclical process that included (i) goal negotiation and setting (ii) planning and measuring confidence (iii) action and (iv) appraisal, feedback and decision making. (ii) Proposed mechanisms of action: successful completion of action plans resulting in incremental improvements in goal sub-skills and self-efficacy. (iii) Predicted outcomes G-AP was likely to impact on: goal attainment and improved rehabilitation outcomes. The process evaluation suggested that each stage of the G-AP framework had a distinct purpose and made a useful contribution to the overall process. Overall, G-AP was acceptable and feasible to use but implementation of novel aspects of the framework (coping planning and measuring confidence) was inconsistent and health professionals had concerns about the potential impact of unmet goals on patients’ wellbeing. Patient reports suggested that (i) the experience of goal non-attainment could facilitate adjustment to limitations resulting from stroke and (ii) 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 (e.g. the patients they see; the input they provide). Goal setting is reportedly used with all or most stroke survivors in these services; however, practice is variable and may be sub-optimal. Conclusions G-AP is the first practice framework which 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 effective 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.