Goal setting in community based stroke rehabilitation: Is where we are at where we want to be?

UK Stroke Forum, 2016 Dr Lesley Scobbie Stroke Association HRH The Princess Margaret Clinical Lecturer (Glasgow Caledonian University); Occupational Therapist (NHS Forth Valley)

Collaborators: Prof Marian Brady, Dr Edward Duncan, Prof Sally Wyke, Dr Diane Dixon

Outline of presentation

• Background

• The Goal setting & Action Planning (G-AP) framework: An overview

• Understanding community stroke rehabilitation contexts and ‘routine’ goal setting practice: UK wide survey

• G-AP Vs ‘routine’ practice: the same or different?

• Implications for research and practice

Background

• Stroke causes more complex disability than any other condition (Adamson, Journal of Stroke & Cerebrovascular Diseases 2004)

• 46% of stroke survivors require ongoing community rehabilitation (Sentinel Stroke National Audit Programme; National Results, 2015)

• Goal setting recommended in stroke clinical guidelines (Scottish Intercollegiate Guidelines Network 2010; Royal College of Physicians 2016)

• Stroke survivors living at home have important goals they hope to achieve (Struggling to Recover, Stroke Association 2012)

• However, many report unmet needs & emotional difficulties (Unmet needs Survey; Stroke Association 2010)

The G-AP framework: An overview

Theory based goal setting practice framework Key stages

How it works

Replicable

Testable

Optimise goal setting practice

Patient centred

Theory/ evidence based

Team approach

Optimise stroke survivor recovery

Goal attainment

Rehabilitation outcomes

Why develop a practice framework?

Development and Evaluation

Development of goal intentions

Initiation & maintenance of goal behaviour Goal setting

• Self efficacy • Outcome expectancies

• Plans • Appraisal/ Feedback

• Goal specificity • Goal difficulty

Motivational phase

Action phase

Theories relevant to the goal setting process

Goal Setting Theory (Latham & Locke); Health Action Process Approach (Schwarzer; Sniehotta);

Social Cognition Theory (Bandura) Common constructs

(Scobbie et al, Clinical Rehabilitation, 23(4) 2009)

G-AP: Two case study examples

Scobbie, L., et al. (2011) Clinical Rehabilitation; 25(5). Scobbie, L., et al. (2013) BMC Health Services Research; 13(190).

Phone local pool to find out weekend

swim times

Coping Plan

Bullet point list

Phoned the pool as planned

Jenny managed phone call, Felt good about it

• Praise success • ↑self efficacy • Incremental skill

improvement

Discuss and agree on next action plan to work

towards set goal

I'm not talking clearly; get

back to work

Speak clearly on the phone

Confidence 9/10

G-AP Framework Jenny

G-AP SS held record

Sit driving assessment

Coping Plan

No barriers

Sat driving assessment as

planned

Info not coming in quick enough Disappointed

Decide not to pursue driving goal for the time being

Confidence 10/10

Get back to driving

Getting back to work is really

important

• Provide support • Understand and

accept limitations • Goal reappraisal

G-AP Framework Pete

Evaluate G-AP Vs ‘usual’ GS practice

• Research Questions:

I. What is the nature of community rehabilitation contexts in which G-AP could be delivered?

II. What does ‘usual’ goal setting practice look like in these settings?

Service responses n= 437

Scotland:118 (27%)

England: 279 (64%)

N Ireland: 9 (2%)

Wales: 31 (7%)

12%

36%

17%

6%

5%

11%

13%

Early Supported Discharge Team (ESD)

Community Rehabilitation Team (CRT)

Combined CRT/EDS

Hospital based outreach

Reablement team

Bespoke team

Other

% Teams (n=427)

Q What title best describes your team?

29%

71%

Q What types of patients are

seen by your team? (n=437)

Stroke patientsonly (n=124)

Mixed patientgroup (n=312)

18%

82%

Unidisciplinary V multidisciplinary teams?

Unidisciplinary (n=72) Multidisciplinary (n=335)

86%

84%

70%

64%

44%

26%

24%

20%

19%

22%

Physiotherapist

Occupational Therapist

Rehabilitation Assistant

Speech and Language Therapist

Nurse

Dietician

Psychology

Social Worker

Doctor

Other

Q What professional groups are represented in your team?

% Teams (n=407)

91%

8%

1% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

All/ most Some None

Q. Is goal setting used by your team with people recovering from stroke? (n=395)

26%

37%

24%

25%

17%

2%

13%

No method

Own method (health professional)

Own method (team)

Goal Attainment Scaling

Canadian Occ Perf Measure

G-AP Framework

Other

Q Which method (if any) does your team use to guide goal setting practice?*

* 25% of services reported use of 2 or more methods % Teams (n=315)

26%

39%

18%

17%

Methods used to guide goal setting practice (n=380)

Formal

Informal

Mixed

No methods

98

93

60

68

59

92

87

62

39

0 10 20 30 40 50 60 70 80 90 100

Find out patient priorities

Set specific goals

Action Plans

Coping plans

Confidence to complete plan

Appraisal

Feedback

Downgrade/ Disengage

Copy of goals & plans

% Teams

Routine use of goal setting activities

60%

92%

62%

98%

‘Routine’ goal setting practice

93%%

Coping Plan

36% Confidence

Confidence

87%

Accessible record of goals & plans

68%

59%

39%

Summary

• G-AP is designed to optimise goal setting practice & stroke

survivor recovery in community rehabilitation settings

• There is strong theoretical rationale and developing evidence

base to support inclusion of key stages of G-AP in practice

• Teams delivering stroke rehabilitation in the community are complex (e.g. service model; staff profile; patient mix)

• ‘Usual’ goal setting practice is highly variable & potentially sub-optimal (e.g. planning, goal adjustment; accessible copy of goals/ plans)

Implications for research & practice

• Does G-AP offer any added value over ‘usual’ goal

setting practice→ effectiveness

• How can G-AP (or any other goal setting intervention)

be delivered in different team settings with individual

stroke survivors→ implementation

• Goal attainment and goal adjustment can enhance

recovery → outcomes

PLEASE CONTACT ME IF YOU WOULD LIKE A COPY OF THE SLIDES

Any Questions? Lesley.Scobbie@gcu.ac.uk

References

Stroke Association: State of the Nation Stroke Statistics; London, 2015.

Royal College of Physicians: Sentinel Stroke National Audit Programme; National Results, 2016 (https://www.strokeaudit.org/Documents/Results/National/JulSep2015/JulSep2015-PublicReport.aspx)

Adamson J et al. Is stroke the commonest cause of disability? Journal of Stroke & Cerebrovascular Diseases 2004;13(4):171-7.

Feigin VL et al. Lancet. 2014 Jan 18;383(9913):245-54.

Stroke Association: Struggling to recover, 2012.

Stroke Association: Unmet needs survey , 2010.

Royal College of Physicians. National Clinical Guidelines for Stroke 5th Edition. 2016.

SIGN 118 Guidelines: Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning. Scottish Intercollegiate Guidelines Network. Scobbie, L. et al. Identifying and applying psychological theory to setting and achieving rehabilitation goals. Clinical Rehabilitation; 2009; 23:231-333. Scobbie L. et al. Goal-setting and action planning in the rehabilitation setting: development of theoretically informed practice framework. Clinical Rehabilitation; 2011, 25:468-482. Scobbie, L. et al. Implementing a framework for goal setting in community based stroke rehabilitation: a process evaluation. BMC Health Services Research 2013, 13:190. Scobbie L. et al. Goal setting practice in services delivering community-based stroke rehabilitation: A United Kingdom (UK) wide survey. Disability & Rehabilitation. 2015; 37(14) 1291-1298.