Development and field testing of a standardised goal setting package for person-centred discharge care planning in stroke

Rebecca Barnden, Dominique A. Cadilhac, Natasha A. Lannin, Ian Kneebone, Deborah Hersh, Erin Godecke, Rene Stolwyk, Tara Purvis, Rebecca Nicks, Michelle Farquhar, Stephanie Gleeson, Carol Gore, Kelsie Herrmann, Nadine E. Andrew

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4 Citations (Scopus)


Objective: Develop and test a person-centred goal-setting package for discharge care planning in acute and rehabilitation stroke units. Methods: A multidisciplinary, expert working group (n = 15), and consumer group (n = 4) was convened. A multistage iterative approach was used to develop and test the package. Stages included: (i) contextual understanding, (ii) package development, and (iii) clinician training and field-testing in acute and rehabilitation settings. Observational field notes were taken and clinicians' perspectives captured using semi-structured focus groups post-testing. Results: The final package included a 34-item menu aligned with a manual containing: guideline summaries; common goals; goal metrics based on the SMART Goal Evaluation Method (SMART-GEM); evidence-based strategies; and worked examples. Twenty-three clinicians attended training. Clinician observations (n = 5) indicated that: the package could be incorporated into practice; a range of person-centred goals were set; and opportunities provided to raise additional issues. Clinician feedback (n = 8) suggested the package was useful and facilitated person-centred goal-setting. Enablers included potential for incorporation into existing processes and beliefs that it promoted person-centred care. Barriers included additional time. Conclusion: The package demonstrated potential to facilitate comprehensive person-centred goal-setting for patients with stroke. Innovation: We developed an innovative approach to support structured person-centred goal setting in clinical and research settings.

Original languageEnglish
Article number100008
Number of pages8
JournalPEC Innovation
Publication statusPublished - Dec 2022


  • Discharge planning
  • Goal attainment scaling
  • Goal-setting
  • Person-centred care
  • Stroke

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