An interactive education session and follow-up support as a strategy to improve clinicians' goal-writing skills: a randomized controlled trial

Implementing a tailored, co-designed goal-setting implementation package in rehabilitation services: a process evaluation

PURPOSE

This study aims to evaluate the process of implementing an evidence-based goal-setting package into five rehabilitation services across the continuum of rehabilitation.

MATERIALS AND METHODS

This study used a mixed methods approach guided by Medical Research Council (MRC) recommendations for conducting process evaluations, the RE-AIM framework, and the Theoretical Domains Framework (TDF). This study will evaluate the reach, adoption, implementation, and maintenance of the goal-setting package over six months.

RESULTS

Environmental context and resources, the clinician's social and professional role and identity, social influences and clinician beliefs about goal-setting consequences and individuals' capabilities were all identified as barriers or enablers throughout the implementation process. Community rehabilitation services faced challenges implementing paper-based resources, whilst inpatient rehabilitation sites faced challenges engaging nursing staff in the interdisciplinary approach to goal-setting. Social influences were an enabler in two sites that used the case conference format to facilitate setting common goals. Clinicians in all sites continued to express difficulties implementing shared decision-making with people who had cognitive impairments or were no longer progressing in their rehabilitation.

CONCLUSIONS

A team-based approach to implementing the goal-setting interventions centred around the case conference format appeared to be the most successful mode for implementing interdisciplinary person-centred goal-setting.

Are SMART goals fit-for-purpose? Goal planning with mental health service-users in Australian community pharmacies

Goal planning is an important element in brief health interventions provided in primary healthcare settings, with specific, measurable, achievable, realistic/relevant, and timed (SMART) goals recommended as best practice. This study examined the use of SMART goals by Australian community pharmacists providing a brief goal-oriented wellbeing intervention with service-users experiencing severe and persistent mental illnesses (SPMIs), in particular, which aspects of SMART goal planning were incorporated into the documented goals. Goal data from the PharMIbridge Randomized Controlled Trial (RCT) were used to investigate how community pharmacists operationalized SMART goals, goal quality, and which SMART goal planning format aspects were most utilized. Goals were evaluated using the SMART Goal Evaluation Method (SMART-GEM) tool to determine how closely each documented goal met the SMART criteria. Goals were also categorized into five domains describing their content or purpose. Descriptive analysis was used to describe the SMART-GEM evaluation results, and the Kruskal-Wallis H test was used to compare the evaluation results across the goal domains. All goals (n = 512) co-designed with service-users (n = 156) were classified as poor quality when assessed against the SMART guidelines for goal statements, although most goals contained information regarding a specific behaviour and/or action (71.3% and 86.3%, respectively). Less than 25% of goals identified how goal achievement would be measured, with those related to lifestyle and wellbeing behaviours most likely to include measurement information. Additionally, the majority (93.5%) of goals lacked details regarding monitoring goal progress. Study findings raise questions regarding the applicability of the SMART goal format in brief health interventions provided in primary healthcare settings, particularly for service-users experiencing SPMIs. Further research is recommended to identify which elements of SMART goals are most relevant for brief interventions. Additionally, further investigation is needed regarding the impact of SMART goal training or support tools on goal quality.

Finding our Voice: Evaluation of Goal Setting Using the Habits of Preceptors Rubric in Terms of Focus, "SMARTness," and Impact

INTRODUCTION

Effective leadership propels teams from effectiveness to greatness and is accomplished when everyone achieves and contributes their full potential, or "voice." The Clinician Educators Program Teaching and Learning Curriculum fosters preceptor development using the Habits of Preceptors Rubric (HOP-R) to guide participants in finding their precepting "voice." After the HOP-R self-assessment, participants select a habit of focus (HOF) and craft a SMART (specific/measurable/achievable/relevant/time-bound) goal. This report describes a pilot rubric, SMART-EP (emotional intelligence(EI)/professionalism), exploring goal "SMARTness" alongside change (impact) in participants' perceived precepting capabilities.

METHODS

HOP-R self-ratings (2018-2020) and HOF/SMART goals (2019-2020) were retrospectively reviewed by two raters. Perceived preceptor capabilities were measured by analyzing the change in self-assessed habit level ratings between the first/fourth-quarter surveys. SMART goals were categorized by HOF and inclusion of SMART-EP components. Participants were guided in the inclusion of SMART, but not -EP, components.

RESULTS

In aggregate, 120 participants completed HOP-R surveys (2018-2020). Within-subject changes across all 11 habits were significant ( P < .001). For the SMART-EP rubric analysis (2019-2020), 71 participants had an average "SMARTness" score of 3.92 (of 5) with corresponding interrater reliability of 0.91. Goals included 2.77 (of 4) EI traits and 1.72 (of 3) professionalism components.

DISCUSSION

The SMART-EP rubric provided insights into preceptor development opportunities among participants. Beyond SMART components, participants often included elements of EI and professionalism. Ratings confirm and support the consistency of the HOP-R as a tool to assess precepting habits.

Implementation of best practice goal-setting in five rehabilitation services: A mixed-methods evaluation study

OBJECTIVE

This implementation study aimed to enhance the key elements of clinical practice goal-setting across 5 rehabilitation services.

DESIGN

This study followed a participatory action research approach guided by the Knowledge to Action framework.

METHODS

Medical record audits and structured client interviews were conducted prior to and following 12 weeks of implementation, in order to evaluate the success of the goal-setting implementation package.

RESULTS

Medical record audits and interviews conducted pre-implementation (audits n = 132, interviews n = 64), post-implementation (audits n = 130, interviews n = 56) and at 3-month follow-up (audits n = 30) demonstrated varied success across sites. Following implementation 2 sites significantly improved their common goal focus (site 1 p ≤ 0.001, site 2 p = 0.005), these sites also demonstrated a significant increase in clients reporting that they received copies of their rehabilitation goals (site 1 p ≤ 0.001, site 2 p ≤ 0.001). Four sites improved client action planning, feedback and review, and 3 sites enhanced their specificity of goal-setting. At 3-month follow-up 4 sites had continued to improve their common goal focus; however, all sites decreased the specificity of their goal-setting.

CONCLUSION

Elements of the implementation package were successful at enhancing the goal-setting process; however, how the package is implemented within the team may impact outcomes.

Systematic Review of the Effectiveness of Allied Health Clinical Education Programs

INTRODUCTION

Continuing allied health professional (AHP) clinical education is essential to ensure high-quality patient care; however, the effectiveness of current education programs is unclear. This review aimed to determine whether AHP education programs improve the knowledge of AHPs, change their clinical practice behavior, and/or improve patient-related clinical outcome and to identify important components of these programs.

METHODS

Four electronic databases were searched. Controlled clinical trials investigating the effectiveness of clinical education programs were included. Education programs were diverse, varying in design, delivery mode, and intensity. Only therapy-specific AHPs were included. Effectiveness was determined by differences in group outcomes in the domains of AHP knowledge, AHP clinical practice behavior, and patient-related clinical outcomes.

RESULTS

Forty-four studies were identified, of which 26 included physiotherapists only. Most control groups were waitlist, passive dissemination of information, or usual care, limiting comparisons between programs. Changes in AHP knowledge was investigated in 20 trials, with 13 showing an improvement. Thirty studies investigated changes in AHP clinical practice behavior, with half demonstrating a difference between groups. Seventeen studies investigated a patient-related clinical outcome, with five finding a difference between groups. Where improvements in outcomes were demonstrated, programs tended to incorporate self-selection and cater to the learner's contextual needs.

DISCUSSION

AHP knowledge is effectively improved through targeted education programs. To change AHP behavior and patient outcomes, it seems important to incorporate self-selection for the program and consider the learner's individual needs and contexts through mentoring, outreach visits, reflection, and incorporating patient participation in the learning.

Developing tailored theoretically informed goal-setting interventions for rehabilitation services: a co-design approach

Background

Several active ingredients contribute to the purposes and mechanisms of goal-setting in rehabilitation. Active ingredients in the goal-setting process include, interdisciplinary teamworking, shared decision-making, having meaningful and specific goals, and including action planning, coping planning, feedback, and review. Clinicians have expressed barriers and enablers to implementing these active ingredients in rehabilitation teams. Interventions designed to improve goal-setting practices need to be tailored to address context specific barriers and enablers. Attempts to understand and enhance goal-setting practices in rehabilitation settings should be supported using theory, process models and determinant frameworks. Few studies have been undertaken to enhance goal-setting practices in varied case-mix rehabilitation settings.

Methods

This study is part of a larger program of research guided by the Knowledge to Action (KTA) framework. A multisite, participatory, codesign approach was used in five sites to address three stages of the KTA. (1) Focus groups were conducted to understand barriers and enablers to implementing goal-setting at each site. Following the focus groups three staff co-design workshops and one consumer workshop were run at each site to (2) adapt knowledge to local context, and to (3) select and tailor interventions to improve goal-setting practices. Focus groups were analysed using the Theoretical Domains Framework (TDF) and informed the selection of behaviour change techniques incorporated into the implementation plan.

Results

Barriers and enablers identified in this study were consistent with previous research. Clinicians lacked knowledge and understanding of the differences between a goal and an action plan often confusing both terms. Clinicians were unable to demonstrate an understanding of the importance of comprehensive action planning and review processes that extended beyond initial goal-setting. Interventions developed across the sites included staff training modules, a client held workbook, educational rehabilitation service flyers, interdisciplinary goal-based case conference templates, communication goal boards and a key worker model. Implementation plans were specifically established for each site.

Conclusions

Rehabilitation teams continue to struggle to incorporate a truly client-centred, interdisciplinary model of goal-setting in rehabilitation. Whilst clinicians continue to lack understanding of how they can use aspects of goal-setting to enhance client outcomes and autonomy in rehabilitation settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08047-6.

An exploration of goal-setting practices in Queensland rehabilitation services

BACKGROUND

Goals are vital in rehabilitation; however, how goal-setting occurs varies widely in clinical practice. This study aims to review goal-setting practices across the rehabilitation continuum within varied case mix services in Queensland, Australia.

METHOD

A descriptive multisite qualitative case study with medical record audits and interviews of adult rehabilitation clients was used to evaluate four propositions across three inpatient and two community rehabilitation services. The propositions evaluated the process in which goal-setting occurs, action planning and review of goals, as well as the type, specificity and client-centeredness of goals set.

RESULTS

Goals (n = 1120) were often poorly defined, focussed on short term physical functioning and were predominantly set by individual disciplines with the client rather than using an interdisciplinary approach. Clients were not consistently given action plans to pursue goals (n = 59, 18%) and the review of goal progress (n = 60, 18%) was limited. Few clients reported receiving copies of their rehabilitation goals (n = 16, 25%).

CONCLUSION

Goal-setting in rehabilitation should be specific, meaningful and include the client in action planning, feedback and review. However, goal-setting in rehabilitation is often multidisciplinary and unstructured.Implications for rehabilitationBest-practice rehabilitation team goal-negotiation and goal-setting should include a common goal focus and incorporate components of staff and client action planning, coping planning, feedback and review.Rehabilitation clients prefer shared-decision making approaches to setting meaningful and personalised goals, however, require time and support to engage in the goal-setting and negotiation process.Rehabilitation clinicians need training and support to improve their goal negotiation and goal writing skills to create specific, understandable and meaningful goals with rehabilitation clients.

Goal statements in brain injury rehabilitation: A cohort study of client-centredness and relationship with goal outcome

Background:

Currently, there is increasing recognition of the need to use a client-centred approach to goal setting in rehabilitation. However, there is limited research to guide practice with community-dwelling clients with acquired brain injury. An understanding of the characteristics of client-centred goals and the extent to which client-centeredness influences goal outcomes is required.

Objective:

To examine the relationships between the client-centredness of goals and their characteristics, content, recall and outcomes of client-centred goals in brain injury rehabilitation.

Methods:

A prospective cohort design study was employed. Participants were 45 clients with brain injury receiving outpatient rehabilitation, who completed measures of client-centredness after goal setting. Each goal was classified according to whether it was specific, measurable, non-jargonistic, and participation-focussed, included a timeframe and was recalled by participants.

Results:

Participants set 223 goals with 20 clinicians from multiple disciplines. Levels of client-centredness did not differ according to the characteristics, content and recall of goals, with the exception of goal specificity (p< 0.01). Client-centredness was significantly and positively correlated with goal outcomes (p< 0.05).

Conclusions:

The use of client-centred goals is recommended for improved rehabilitation outcomes. Applying goal documentation criteria does not necessarily mean that goals will be client-centred, and highly specific goal statements may not reflect what is important and meaningful to clients.

Quality of goal setting in pediatric rehabilitation-A SMART approach

BACKGROUND

Setting goals for treatment is often the core of the rehabilitation process. The quality of the set goals has however rarely been evaluated. The aims of this study were therefore to assess the quality of goals set in clinical practice of pediatric rehabilitation using SMART criteria (Specific, Measurable, Achievable, Relevant, and Timed) and to assess if the goals were considered relevant from both a client perspective and expertise perspective.

METHODS

In a retrospective multicase study, a total of 161 goals from 42 children with disabilities (cerebral palsy, n = 22; Down syndrome, n = 16; and developmental disability, n = 4) were assessed. The children were 1.5-5.5 years and had previously participated in goal-directed, activity-focused therapy at four pediatric rehabilitation centers. Collaborative goal setting had been used to define the desired treatment outcome. The quality of the goals was assessed using defined SMART criteria.

RESULTS

Specific: All goals could be reliably linked to International Classification of Functioning, Disability and Health-Children and Youth version chapters within the Activity/Participation domain. Measurable: A total of 75% of the goals were rated as having a well-defined scaling; in 20%, the scaling was less clear, and in 5%, a scaling could not be determined. Achievable: A total of 80% of the goals were attained. Relevant: All goals were set in collaboration with the family and could therefore be considered relevant from a client perspective. Relevancy judged from a professional perspective was strengthened by the fact that age, baseline status, and diagnosis had an influence on the choice of goals. Timed: All goals were set within a specific time frame.

CONCLUSIONS

The goals set in clinical practice showed high quality with respect to the SMART criteria. The most difficult part was the construction of the goal attainment scale. The goals settled in clinical practice were considered relevant from both a client perspective and expertise perspective.

A conversation approach based on shared goal-setting and shared decision-making for nurses in cancer aftercare: A developmental study

PURPOSE

This study aimed to develop and pretest a systematic conversation approach for nurses to tailor aftercare to oncology patient's goals, unmet needs and wishes.

METHODS

We used an iterative developmental process for complex interventions: 1. Identifying problems 2. Identifying overall objectives 3. Designing the intervention 4. Pretesting and adapting the intervention.

RESULTS

The main results of the problem identification were: non-systematic and incomplete screening of potential issues, caveats in providing information, and shared decision-making. The overall objective formulated was: To develop a model for aftercare conversations based on shared goal-setting and decision-making. The conversation approach consists of four phases: 1. Preparation of the consultation including a questionnaire, 2. Shared goal-setting by means of a tool visualizing domains of life, and 3. Shared care planning by means of an overview of possible choices in aftercare, a database with health care professionals and a cancer survivorship care plan. 4.

EVALUATION

The results of the pretest revealed that the conversation approach needs to be flexible and tailored to the patient and practice setting, and embedded in the care processes. The conversation approach was perceived as enhancing patient-centeredness and leading to more in-depth consultations.

CONCLUSION

The conversation approach was developed in co-creation with stakeholders. The results of the pretest revealed important implications and suggestions for implementation in routine care. The aftercare conversation approach can be used by nurses to provide tailored patient-centered evidence-based aftercare. Tailored aftercare should support oncology patient's goals, unmet needs and wishes. Further tailoring is needed.

What is required to facilitate implementation of Swedish physical activity on prescription? - interview study with primary healthcare staff and management

Background

The method, Swedish Physical Activity on Prescription (SPAP), has been launched in Swedish healthcare to promote physical activity for prevention and treatment of lifestyle related health disorders. Despite scientific support for the method, and education campaigns, it is used to a limited extent by health professionals. The aim of the study was to describe the views of health professionals on perceived facilitators, barriers and requirements for successful implementation of SPAP in primary healthcare.

Methods

Eighteen semi-structured interviews with stakeholders in SPAP, i.e. ten people working in local or central management and eight primary healthcare professionals in two regional healthcare organisations, were analysed using qualitative content analysis.

Results

We identified an overarching theme regarding requirements for successful implementation of SPAP: Need for knowledge and organisational support, comprising four main categories: Need for increased knowledge and affirmative attitude among health professionals; Need for clear and supportive management; Need for central supporting structures; Need for local supporting structures. Knowledge of the SPAP method content and core components was limited. Confidence in the method varied among health professionals. There was a discrepancy between the central organisation policy documents declaring that disease preventive methods were prioritised and a mandatory assignment, while the health professionals asked for increased interest, support and resources from management, primarily time and supporting structures. There were somewhat conflicting views between primary healthcare professionals and managers concerning perceived barriers and requirements. In contrast to some of the management’s beliefs, all primary healthcare professionals undisputedly acknowledged the importance of promoting physical activity, but they lacked time, written routines and in some cases competence for SPAP counselling.

Conclusion

The study provides knowledge regarding requirements to facilitate the implementation of SPAP in healthcare. There was limited knowledge among health professionals regarding core components of SPAP and how to practise the method, which speaks for in-depth training in the SPAP method. The findings highlight the importance of forming policies and guidelines and establishing organisational supporting structures, and ensuring that these are well known and approved in all parts of the healthcare organisation.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3021-1) contains supplementary material, which is available to authorized users.

Creating Individualized Symptom Management Goals and Strategies for Cancer-Related Fatigue for Patients With Recurrent Ovarian Cancer

BACKGROUND

Cancer-related fatigue (CRF) is one of the most common symptoms among women with recurrent ovarian cancer, yet it remains extremely difficult to manage. Symptom management typically requires patients to set goals and strategies to manage their CRF, but little is known about how to create individualized CRF symptom management goals and strategies.

OBJECTIVE

The aim of this study was to describe cancer patients' goals and strategies for managing CRF along with their process of individualizing both.

METHODS

This study is a qualitative analysis with supportive quantitative description of a Web-based symptom management randomized clinical trial, the WRITE (Written Representational Intervention to Ease) Symptoms study. Researchers conducted a content analysis on 47 participants' CRF symptom care plans to identify common themes in participants' goals, categorize strategies, and describe the individualization process.

RESULTS

Four general themes were identified among participants' CRF goals: (1) enjoying time with friends and family, (2) doing the things I enjoy, (3) having energy to be physically active, and (4) keeping up with what I need to do. Cancer-related fatigue strategies were categorized into 13 groups including conserving energy, increasing activity, and talking with healthcare providers. A multistep individualization process resulted in personally meaningful strategies.

CONCLUSIONS

The process by which participants individualized their CRF strategies consisted of identifying, confirming, testing, and evaluating different CRF strategies and resulted in refined, specific, and individualized strategies intended to eventually ensure participants achieve their goal.

IMPLICATIONS FOR PRACTICE

Clinicians can assist patients in individualizing their CRF goals and strategies. Individualization of CRF goals and strategies assists patients in visualizing how improving CRF will impact their life.

Breaking Barriers to Effective Type 2 Diabetes Management: Findings from the use of the OPTIMA© Questionnaire in Clinical Practice

Background

The OPTIMA© (MSD, Courbevoie, France) questionnaire was developed to promote shared decisions and the set-up of specific micro-objectives in clinical practice by optimizing communication between type 2 diabetes (T2DM) patients and their physicians. The present study aimed to assess OPTIMA in clinical practice.

Methods

A cross-sectional multicenter observational study was conducted in France from 2012 to 2014. During routine consultation, patients completed one of the five modules of the OPTIMA questionnaire (Physical activity, Diet, Treatment, Knowledge of the disease or Self-monitoring of blood glucose). The rate of SMART (specific, measurable, acceptable, realistic, timely) micro-objective set-up following the use of the questionnaire was assessed. Data on how patients felt about their diabetes management (beliefs concerning actions, how easy they were to do and how often they were done in practice) were gathered. Finally, patients’ and physicians’ opinions on OPTIMA were assessed using the PRAgmatic Content and face validity Test (PRAC-Test© (Mapi, Lyon, France) evaluation questionnaire.

Results

Overall, 807 patients were included by 186 physicians. While 92.7 % of consultations led to the set-up of a micro-objective, only 22.3 % were SMART micro-objectives: Physical activity module (34.3 %), Diet module (9.6 %), Treatment module (16.4 %), Knowledge of the disease module (25.2 %), and self-monitoring of blood glucose module (29.5 %). Among patients completing the Physical activity module, 79.0 % reported that they believed physical activity was useful, 35.0 % that it was easy, and 25.8 % that they regularly practised it. PRAC-Test results showed that OPTIMA was a useful and easy-to-use questionnaire that promotes communication between physicians and their patients according to 92.8 % of patients and 69.4 % of physicians.

Conclusion

The OPTIMA questionnaire facilitates communication between patients and their physicians and promotes the set-up of micro-objectives concerning T2DM management. The Physical activity module was the most likely of the five modules in the questionnaire to lead to the set-up of SMART micro-objectives.

Funding

MSD France.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-016-0341-6) contains supplementary material, which is available to authorized users.

A 'SMART' way to determine treatment goals in pharmacotherapy education

AIM

Determining treatment goals is an important part of the treatment decision-making process, but medical students are not trained in a structural way on how to define these goals. 'SMART' criteria are widely used in non-medical professions for determining goals and may improve treatment goal setting. The aim of this study was to assess the effect of implementation of SMART criteria on medical students' ability to set treatment goals and to analyze the effects on treatment choice and monitoring.

METHODS

We performed a prospective, randomized controlled minimal intervention study with one control and two intervention groups (WHO group and SMART group). Second year medical students had to complete a WHO six step treatment plan for four written case reports of patients with asthma. The treatment plans were assessed using a standard scoring sheet developed by a Delphi procedure among respiratory physicians from all eight university medical centres in the Netherlands.

RESULTS

A total of 251 second year medical students participated. The SMART group had significantly higher scores for setting treatment goals than the WHO and control groups (68.5 % vs. 29.6 % and 30.8 %, respectively, both P < 0.001). The SMART group also had significantly better scores for treatment monitoring than the WHO and control groups (34.2 % vs. 19.3 % and 24.6 %, respectively, both P < 0.001). There were no between group differences in treatment choice. Regardless of the study group, better setting of treatment goals was associated with better treatment monitoring, an association not reported earlier.

CONCLUSION

SMART criteria improve the setting of treatment goals and treatment monitoring.

The development, content validity and inter-rater reliability of the SMART-Goal Evaluation Method: A standardised method for evaluating clinical goals

INTRODUCTION

Goal setting is a complex skill. The use of formal goal writing procedures (including the use of the SMART goal model) has been advocated. However, a standardised method of writing and evaluating SMART goals is currently lacking. This study comprised of two phases. The aims of phase one was to (i) develop the SMART Goal Evaluation Method (SMART-GEM) based on a SMART goal model; and (ii) investigate the content validity of the SMART-GEM. The aim of phase two of the study was to test the inter-rater reliability of the SMART-GEM.

METHODS

Development of the SMART- GEM involved defining and constructing evaluation criteria suitable for auditing goal statements. A content validity assessment was conducted using an expert panel of Occupational Therapists (n = 10). Inter-rater reliability of the SMART-GEM was examined using a purposive sample of multiple raters (n = 24).

RESULTS

The SMART- GEM was rated as having good content validity (individual items CVI ranged from 0.90 to 1.00; total SMART- GEM CVI = 0.99, ρ = 0.05). Agreement between raters on individual items ranged from poor (κ = 0.254) to excellent (κ = 0.965) and agreement of overall grades was fair to good (κ = 0.582). Inter-rater agreement on total scores was found to be very good (ICC = 0.895, 95% CI = 0.743 to 0.986, ρ = 0.001) with excellent internal consistency (α = 0.995).

CONCLUSION

The SMART-GEM demonstrated good construct validity and very good inter-rater reliability on total score and shows promise as a standardised method to writing and evaluating clinical goals.

Goal setting and strategies to enhance goal pursuit for adults with acquired disability participating in rehabilitation

BACKGROUND

Goal setting is considered a key component of rehabilitation for adults with acquired disability, yet there is little consensus regarding the best strategies for undertaking goal setting and in which clinical contexts. It has also been unclear what effect, if any, goal setting has on health outcomes after rehabilitation.

OBJECTIVES

To assess the effects of goal setting and strategies to enhance the pursuit of goals (i.e. how goals and progress towards goals are communicated, used, or shared) on improving health outcomes in adults with acquired disability participating in rehabilitation.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, four other databases and three trials registers to December 2013, together with reference checking, citation searching and contact with study authors to identify additional studies. We did not impose any language or date restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs and quasi-RCTs evaluating the effects of goal setting or strategies to enhance goal pursuit in the context of adult rehabilitation for acquired disability.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed search results for inclusion. Grey literature searches were conducted and reviewed by a single author. Two authors independently extracted data and assessed risk of bias for included studies. We contacted study authors for additional information.

MAIN RESULTS

We included 39 studies (27 RCTs, 6 cluster-RCTs, and 6 quasi-RCTs) involving 2846 participants in total. Studies ranged widely regarding clinical context and participants' primary health conditions. The most common health conditions included musculoskeletal disorders, brain injury, chronic pain, mental health conditions, and cardiovascular disease.Eighteen studies compared goal setting, with or without strategies to enhance goal pursuit, to no goal setting. These studies provide very low quality evidence that including any type of goal setting in the practice of adult rehabilitation is better than no goal setting for health-related quality of life or self-reported emotional status (8 studies; 446 participants; standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.17 to 0.88, indicative of a moderate effect size) and self-efficacy (3 studies; 108 participants; SMD 1.07, 95% CI 0.64 to 1.49, indicative of a moderate to large effect size). The evidence is inconclusive regarding whether goal setting results in improvements in social participation or activity levels, body structure or function, or levels of patient engagement in the rehabilitation process. Insufficient data are available to determine whether or not goal setting is associated with more or fewer adverse events compared to no goal setting.Fourteen studies compared structured goal setting approaches, with or without strategies to enhance goal pursuit, to 'usual care' that may have involved some goal setting but where no structured approach was followed. These studies provide very low quality evidence that more structured goal setting results in higher patient self-efficacy (2 studies; 134 participants; SMD 0.37, 95% CI 0.02 to 0.71, indicative of a small effect size) and low quality evidence for greater satisfaction with service delivery (5 studies; 309 participants; SMD 0.33, 95% CI 0.10 to 0.56, indicative of a small effect size). The evidence was inconclusive regarding whether more structured goal setting approaches result in higher health-related quality of life or self-reported emotional status, social participation, activity levels, or improvements in body structure or function. Three studies in this group reported on adverse events (death, re-hospitalisation, or worsening symptoms), but insufficient data are available to determine whether structured goal setting is associated with more or fewer adverse events than usual care.A moderate degree of heterogeneity was observed in outcomes across all studies, but an insufficient number of studies was available to permit subgroup analysis to explore the reasons for this heterogeneity. The review also considers studies which investigate the effects of different approaches to enhancing goal pursuit, and studies which investigate different structured goal setting approaches. It also reports on secondary outcomes including goal attainment and healthcare utilisation.

AUTHORS' CONCLUSIONS

There is some very low quality evidence that goal setting may improve some outcomes for adults receiving rehabilitation for acquired disability. The best of this evidence appears to favour positive effects for psychosocial outcomes (i.e. health-related quality of life, emotional status, and self-efficacy) rather than physical ones. Due to study limitations, there is considerable uncertainty regarding these effects however, and further research is highly likely to change reported estimates of effect.

Difficulties experienced in setting and achieving goals by participants of a falls prevention programme: a mixed-methods evaluation

PURPOSE

To evaluate the ability of participants of a falls prevention programme to set and achieve goals.

METHODS

The study used a prospective longitudinal design and a mixed-methods approach to data collection. Study participants were (1) 220 older adults participating in a 15-week combined exercise and education falls prevention programme and (2) 9 practitioners (3 home-care nurses, 5 community workers, and an exercise physiologist) involved in delivering the programme. Data from goal-setting forms were analyzed, and descriptive statistics were used to determine the number of appropriate goals set and achieved. Data were analyzed according to programme setting (home- or group-based) and whether or not participants were classified as being from a Culturally and Linguistically Diverse (CALD) background in the Australian context. Semi-structured interviews with programme practitioners were thematically analyzed.

RESULTS

A total of 144 respondents (n=75 CALD group, n=41 non-CALD group, n=6 CALD home, n=22 non-CALD home) set 178 goals. Only 101 (57%) goals could be evaluated according to achievement, because participants set goals that focused on health state instead of behaviour, set goals not relevant to falls prevention, used inappropriate constructs to measure goal achievement, and either did not review their goals or dropped out of the programme before goal review. Of these 101 goals, 64 were achieved. Practitioners described their own difficulties in understanding the process of setting health behaviour goals along with communication, cultural, and logistic difficulties.

CONCLUSIONS

Both CALD and non-CALD participants and those participating in both group- and home-based programmes experienced difficulty in setting and achieving goals to facilitate behaviour change for falls prevention. Data suggest that home-based participants had more difficulty in setting goals than their group-based counterparts and, to a lesser extent, that CALD participants experienced more difficulty in setting goals than their non-CALD counterparts. The use of a guided approach to goal setting and the need for more specific practitioner training and follow-up support regarding goal setting in the context of a falls prevention programme should be considered.

Career-long learning: relationship between cognitive and metacognitive skills

OBJECTIVES

 Physicians need metacognitive skills including reflection and goal generation for effective lifelong learning (LLL). These skills are not readily assessed and may not correlate with cognitive skills. We examined early-career physicians' metacognition and relationships between metacognitive skills, cognitive skills, and orientation toward LLL.

METHODS

 Pediatric fellows at UCSF document career progress in annual Individual Development Plans (IDPs). To assess metacognitive skills, we scored narratives in IDPs with a Reflective Ability Rubric (RAR) and goal setting with a SMART Goal Rubric (SMART-GR: consists of global IDP score and four IDP domain subscores). To assess cognitive skills, we collected American Board of Pediatrics scores (ABP), and to measure orientation toward LLL, fellows completed the Jefferson Scale (JeffSPLL). We used Spearman's correlation to examine relationships between scores.

RESULTS

 About 57/66 (86%) fellows participated. Mean scores were: RAR 2.4 ± 1.3 (scale 0-6); SMART-GR global IDP 2.8 ± 1.0, (1-5); JeffSPLL 46.3 ± 3.9 (14-56); and ABP 559.4 ± 75.7. RAR scores correlated significantly with SMART-GR scores but metacognitive measures did not correlate with ABP scores.

CONCLUSIONS

 Our study suggests early-career physicians may have limited metacognitive skills; cognitive and metacognitive skills do not correlate; and orientation toward LLL does not predict metacognitive skills. Thus, we need improved methods to teach and assess metacognition.

SMART, SMARTER, SMARTEST: the influence of peer groups compared to practice visits on the quality of action plans

BACKGROUND

It has been reported that appraisal by peers can be effective.

AIM

To investigate whether feedback from a peer group (PG) compared to that by a staff member during a practice visit (PV) is as effective in improving the quality of action plans.

METHODS

Seventy-three general practitioner (GP) trainers randomized into either a PG or PV were instructed to draw up action plans using the SMART criteria to realize the goals set in their personal development plans (PDPs). To improve action plans, feedback was given in either PG or PV. Quality of baseline and follow-up action plans, operationalized as the SMARTness with which plans were formulated, was assessed using a study-specific instrument.

RESULTS

Response rate for submitting both baseline and follow-up action plans was 89% in the PG versus 79% in the PV. It was feasible to determine scores on all SMART criteria, except for the criterion 'Acceptability'. Significant improvement was made on the remaining four criteria irrespective of the feedback setting.

CONCLUSIONS

PGs cost less and seem equally effective in improving the SMARTness of the action plans. Moreover, they also seem to stimulate GP trainers more to write a PDP. Therefore, they may be favoured over PVs.

Navigating patient-centered goal setting in inpatient stroke rehabilitation: how clinicians control the process to meet perceived professional responsibilities

OBJECTIVE

Patient-centered goal setting, while central to contemporary rehabilitation, has been associated with growing uncertainty regarding its application in clinical practice. We aimed to examine the application of goal setting in inpatient stroke rehabilitation.

METHODS

Data collected from 44 participants (nine patients, seven family members, 28 health professionals), using multiple data sources (interviews, recorded clinical sessions, team meetings, participant-observation, and clinical documentation), were analyzed using constant comparative methods.

RESULTS

Certain goals (characterized by short timeframes, conservative estimation of outcomes, and physical function) were privileged over others. Involvement of patients and family in goal setting resulted in interactional dilemmas when their objectives, skills and perceived capacity did not align with privileged goals. When alignment did occur, greater patient involvement still did not appear to influence clinical reasoning.

CONCLUSION

This study raises questions about how 'patient-centered' current goal setting practices are and whether a 'patient-centered' approach is even possible in inpatient stroke rehabilitation when considering predominant funding and health system models.

PRACTICE IMPLICATIONS

For 'patient-centered' goal setting to be more than rhetorical, clinicians need to examine the values they attribute to certain types of goals, the influence of organizational drivers on goal selection, and how goals are actually used to influence clinical practice.