Feasibility and Implementation Determinants of a Structured Goal Setting and Goal Management System

Theory-based, client-engaged goal setting and goal management is a fundamental occupational therapy practice for adults with chronic conditions (American Occupational Therapy Association [AOTA], 2021). High-quality goal setting and goal management is an iterative process in which the clinician educates the client on the purpose of therapy and the importance of active client engagement during the process; facilitates reflection on their occupational performance; and guides formulation, review, and adjustment of goals and plans (Kang et al., 2022; Lenzen et al., 2017). These processes offer the clinician an opportunity to build a therapeutic alliance with the client to understand their goals, participation, and environment (Jesus et al., 2022; Vermunt et al., 2017; Yun & Choi, 2019). On the basis of these insights and the client’s goals, the clinician can provide person-centered occupational therapy care tailored to promote the client’s health and participation (AOTA, 2021).

Despite this, high-quality goal setting and goal management is not yet widely implemented in rehabilitation (Kang et al., 2022). Not all theory-based goal setting and goal management components are comprehensively implemented in practice (Kang et al., 2022). Active client engagement during goal setting and goal management is also not always promoted, despite its importance in achieving better outcomes (Kang et al., 2022). These limitations may be attributed to a lack of an effective system to guide comprehensive theory-based practice (Stevens et al., 2013). Stevens et al. (2013) reviewed 11 existing systems and concluded that none of them address all essential goal setting and goal management components. This may also explain why clinicians do not widely use the existing systems (Scobbie et al., 2015). In one survey study, only 2% to 30% of clinicians reported that they used existing standardized methods, such as the Canadian Occupational Performance Measure (COPM; Law et al., 1990), goal attainment scaling (Turner-Stokes, 2009), and the goal setting and action planning framework (Scobbie et al., 2011, 2015). Indeed, clinicians have expressed difficulties engaging their clients using the existing systems (Chenq et al., 2002; Stolee et al., 2012). To address these two challenges to clinical implementation, calls have been made for the development of a system that can guide clinicians through the process of comprehensive theory-based, client-engaging goal setting and goal management (Levack & Siegert, 2014).

We developed a new system, called MyGoals, with the primary aims of facilitating the implementation of comprehensive theory-based goal setting and goal management components and promoting active client engagement during the process. Unlike other existing systems, MyGoals provides six structured activities with clinician scripts and client worksheets, which are intentionally designed to address all theory-based goal setting and goal management components. It is important to note that MyGoals was not developed for prescriptive purposes; instead, it provides occupational therapists with a concrete structure to easily implement theory-based, client-engaged goal setting and goal management. For instance, one of MyGoals’ activities guides clients to brainstorm occupation-based goals rather than impairment-based goals. The clinician scripts ensure that occupational therapists address important theoretical constructs with clients by including theory-informed intervention questions (e.g., for positive outcome expectancy: “How much benefit do you think you would have by reaching your goal?”). The client worksheet has clients write down their own goals, which is one way of actively engaging in the goal setting and goal management process. As such, MyGoals was developed to guide occupational therapists to implement high-quality practice but also allows them to personalize intervention content. The ultimate aim of MyGoals is to enable clients to achieve their personally meaningful rehabilitation goals. The main target population of MyGoals is adults with chronic conditions in community-based rehabilitation, given that currently there is no evidence-based system for this population and context (Kang & Foster, 2022).

To improve the rigor of MyGoals development, we used Intervention Mapping (Fernandez, Ruiter, et al., 2019) and Implementation Mapping (Fernandez, Ten Hoor, et al., 2019) in collaboration with occupational therapy and client stakeholders, along with social cognitive theory (Bandura, 1977, 1989, 2001; Bandura et al., 1997), self-determination theory (Deci & Ryan, 2000; Ryan & Deci, 2000), the theory of intentional action control (Bieleke et al., 2021; Gollwitzer, 1993, 1999), and the taxonomy of behavior change methods (Kok et al., 2016). Three papers detailing the development process and its theoretical background are under review or have been published elsewhere (Kang, 2023; Kang & Foster, 2022, in press).

To ensure the successful translation of MyGoals to real-world clinical practice, it is important to understand clinicians’ perspectives on the intervention and optimize it on the basis of their feedback. If clinicians perceive the system as feasible or beneficial, they may be more likely to implement it in their practice. Therefore, in this study we aimed to determine and optimize the feasibility of MyGoals for occupational therapists. We expected that MyGoals would have good acceptability, appropriateness, feasibility, credibility, and expectancy for occupational therapists. We also explored MyGoals’ implementation barriers and facilitators and occupational therapists’ perspectives on the potential positive outcomes of MyGoals through semistructured interviews.

This was a mixed-methods feasibility study to determine the acceptability, appropriateness, feasibility, credibility, and expectancy of MyGoals in occupational therapy. We also explored the potential positive outcomes of MyGoals and relevant implementation determinants. Figure 1 displays the overall flow of the study. One researcher (Eunyoung Kang) led audit and feedback processes and provided feedback about the participants’ MyGoals implementation with specific action steps after auditing their session in real time (details are described in Kang & Foster, 2022b). The participants chose their preferred delivery method of audit and feedback. The institutional review board of the Washington University School of Medicine approved this project. All participants provided informed consent.

This study was completed using in-person and Zoom meetings at a research-based university in the United States.

Inclusion criteria included individuals who were age ≥18 yr, were a licensed occupational therapist, and had at least 1 yr of community-based goal setting and goal management–related clinical experience with adults with chronic conditions. The last criterion was operationally defined as a person who said “Yes” to the following question: “Do you have at least one year of professional clinical experience relevant to community-based goal setting and goal management for adults with chronic conditions?” We recruited occupational therapist participants using word of mouth and snowball sampling.

We enrolled clients who were age ≥18 yr; had one or more chronic conditions; and had no severe cognitive or communication impairment, operationally defined as having a total Montreal Cognitive Assessment (MoCA) score ≤21 (Nasreddine et al., 2005). Enrolled participants had diverse health conditions, including arthritis, cancer, Crohn’s disease, diabetes, gout, heart disease, hypertension, multiple sclerosis, nerve damage, osteopenia, osteoporosis, Parkinson’s disease, rheumatoid arthritis, and schizophrenia.

MyGoals consists of six structured activities: (1) Education, (2) Reflection, (3) Find My Goals, (4) Make My Goals, (5) Make My Plans, and (6) My Progress. It is designed to be used over the course of rehabilitation in multiple intervention sessions; however, for the sake of feasibility testing in this study two MyGoals sessions were conducted. MyGoals was delivered in two in-person sessions spaced 1 wk apart using the MyGoals clinician manual and MyGoals client worksheets. In the first visit (1.5 hr), the clinician implemented MyGoals Activities No. 1 (Education) through No. 5 (Make My Plans). During these activities, the clinician educated the client on the overall purpose of goal setting and goal management and the importance of active client engagement during the process, guided them to reflect on their current participation, and facilitated goal and plan formulation. In the second visit (0.5 hr), the clinician implemented MyGoals Activity No. 6 (My Progress), in which they guided the client in monitoring and reviewing their goal progress and adjusting their goals and plans, if necessary. More details about MyGoals are described elsewhere (Kang & Foster, in press).

To promote active client engagement during goal setting and goal management, MyGoals was developed using an empowerment-based communication approach. This approach includes using open-ended questions to prompt the client to reflect and discuss their perspectives, use active listening and guided discovery, and so on. We reported data for the current study using the Template for Intervention Description and Replication checklist (see the Supplemental Material, available online with this article at https://research.aota.org/ajot; Hoffmann et al., 2014).

Occupational therapist participants reported their sex, race, ethnicity, and years of professional experience at the first visit and completed all outcome measures and an interview during the last visit. Client participants reported their age, sex, race, ethnicity, education level, and health conditions and completed the MoCA during the first visit.

Using Proctor et al.’s (2011) guidelines, we conceptually defined acceptability, appropriateness, and feasibility. Acceptability was defined as the occupational therapists’ perceptions of the degree to which MyGoals is agreeable, palatable, or satisfactory. Appropriateness was defined as the occupational therapists’ perceptions of the perceived fit, relevance, or compatibility of MyGoals. Feasibility was defined as the occupational therapists’ perceptions of the extent to which MyGoals can be successfully conducted in community-based rehabilitation. We used the Acceptability of Intervention Measure (AIM), the Intervention Appropriateness Measure (IAM), and the Feasibility of Intervention Measure (FIM) because these are commonly used, valid, and reliable assessments (Weiner et al., 2017). Each measure has four items that are rated on 5-point scales (1 = completely disagree to 5 = completely agree). We used scale scores ≥16 as benchmarks for good outcomes because item scores of 4 to 5 indicate that the respondent agrees or completely agrees that MyGoals is acceptable, appropriate, or feasible.

We evaluated the extent to which occupational therapists viewed MyGoals as believable, convincing, and logical (i.e., credibility) and their expectation that MyGoals could enable clients to achieve their personally meaningful goals (i.e., expectancy) using the self-report Credibility and Expectancy Questionnaire (CEQ; Devilly & Borkovec, 2000). The CEQ demonstrates high internal consistency and has good test–retest reliability (Devilly & Borkovec, 2000). It includes three items for each scale (Credibility and Expectancy). Credibility and one of the Expectancy items were rated on a 9-point scale (e.g., 1 = not at all logical to 9 = very logical). The two other Expectancy items were rated on an 11-point scale (0%–100%). We recoded the 11-point scale into a 9-point scale by collapsing 40%, 50%, and 60% responses into one response (i.e., 5) for analysis (0% = 1, 100% = 9; Kemp et al., 2014). Each scale total score can range from 3 to 27, with higher scores indicating higher credibility and expectancy.

We conducted individual 1-hr semistructured interviews to explore occupational therapists’ perspectives on the acceptability, appropriateness, and feasibility of MyGoals. We also explored the potential positive outcomes of using MyGoals in practice, comparative benefits of MyGoals compared with other systems, and factors that can facilitate or hinder MyGoals implementation in practice (i.e., implementation determinants). These questions were adapted from the Consolidated Framework for Implementation Research (CFIR) Interview Guide Tool (CFIR Research Team, 2021). The interview guide is available in the Supplemental Material. We audio recorded the interviews and transcribed them verbatim.

We used descriptive statistics to analyze all quantitative data. We determined the acceptability, appropriateness, and feasibility of MyGoals using the predetermined benchmarks of the AIM, IAM, and FIM. We analyzed the interview data using the six phases of thematic analysis to understand the occupational therapists’ perspectives on acceptability, appropriateness, feasibility, and implementation determinants (Braun & Clarke, 2006). We used the CFIR Interview Guide Tool to categorize the identified MyGoals implementation determinants (Damschroder et al., 2009). Using investigator triangulation, two coders (Kang and Julie Chen) independently analyzed all transcripts (Carter et al., 2014). Because Kang was the interviewer and audit and feedback session provider, we had two other authors (Chen and Erin R. Foster) help address reflexivity, reduce bias, and draw sound analysis results (Tolley et al., 2016). Qualitative data were organized on the basis of the interview guide and CFIR Interview Guide Tool. If there were any discrepancies, the two coders solved them through discussion or consultation with Foster.

Seven occupational therapists participated in this study. All participants self-identified as female, White, and not Hispanic or Latino. The mean number of years of professional experience in rehabilitation was 9.3 (SD = 5.9).

The quantitative acceptability, appropriateness, feasibility, credibility, and expectancy results are presented in Table 1. The acceptability (M = 18.1, SD = 1.9, range = 15–20), appropriateness (M = 17.9, SD = 2.2, range = 14–20), and feasibility scores (M = 17.3, SD = 2.1, range = 15–20) were higher than the benchmark of 16. The CEQ Credibility (M = 22.1, SD = 5, range = 14–27) and Expectancy scores (M = 20.6, SD = 4.3, range = 15–27) can be considered high because they were higher than 75% of the maximum score, which was used as a benchmark of high credibility and expectancy in previous research (Smeets et al., 2008).

Qualitative results on the acceptability, appropriateness, feasibility, implementation determinants, and suggestions for improvement are synthesized in Figure 2. The occupational therapists suggested that limited clinical time is a barrier to the acceptability and feasibility of MyGoals; however, they also noted that it is worthwhile to spend extra practice time because it can lead to better outcomes:

Participants also reported that documentation may be a potential barrier for some occupational therapists: “[Documentation] might be hard for some.” Thus, they mentioned clinician education regarding documentation and providing documentation support as being a potential solution: “having an epic smart phrase for it . . . saves a lot of time on documentation.” The occupational therapists provided additional suggestions to improve MyGoals across intervention-, client-, and clinician-related aspects (e.g., streamline the intervention, provide an electronic MyGoals manual).

Qualitative information on which characteristics of MyGoals promoted which implementation (or clinician-related) benefit, and then how that further facilitated the clients’ health (or client-related benefit), is presented in Table 2. Overall, the occupational therapists perceived MyGoals as having positive effects on goal setting and goal management–specific, non–goal-specific, and overall rehabilitation areas. For instance, MyGoals’ open-ended questions, which were designed to facilitate a holistic goal conversation, helps the clinician guide the client to have better awareness of their current and desired participation. Therefore, the client is able to better explore their goals and prepare for goal formulation:

MyGoals’ step-by-step structure and empowerment approach made it easier for the clinician to help the client gain goal setting and goal management skills:

The structure provided by MyGoals also supported the clinician in easily implementing theory-based client-engaged goal setting and goal management as well as better person-centered care in general:

Occupational therapists also indicated that “having more structure to the goal and goal writing process . . . help[s] you identify ways to set [the] intervention.”

Occupational therapists perceived that MyGoals has the potential to facilitate active client engagement not only for the goal setting and goal management process itself but also for subsequent rehabilitation:

In this study, we evaluated the acceptability, appropriateness, feasibility, credibility, and expectancy of MyGoals in occupational therapy. We also explored occupational therapists’ perspectives on MyGoals’ implementation determinants, potential positive outcomes, and characteristics. As hypothesized, MyGoals had high acceptability, appropriateness, feasibility, credibility, and expectancy among occupational therapists. MyGoals implementation determinants included the individuals involved, the inner setting (the environment in which the intervention) is carried out, and intervention characteristic domains. Occupational therapists identified several MyGoals’ client- and clinician-related potential positive outcomes and comparative benefits. To our knowledge, this is the first study to evaluate occupational therapy perspectives on a structured and comprehensive goal setting and goal management system (Kang et al., 2022).

MyGoals was considered acceptable, appropriate, feasible, credible, and promising. High acceptability, appropriateness, and feasibility are considered key indicators of successful implementation (Weiner et al., 2017). When clinicians view MyGoals as useful, credible, and promising they will be more likely to actively incorporate it into their clinical practice. Therefore, MyGoals as a structured system has the potential to guide clinicians in implementing high-quality goal setting and goal management.

The occupational therapists reported client- and clinician-related potential positive outcomes of MyGoals. The client-related aspects included goal setting and goal management process-related benefits (e.g., goal tracking, developing concrete plans) as well as outcomes (e.g., better health outcomes, client empowerment). The potential benefits also included overall rehabilitation-related benefits, such as active client engagement throughout the rehabilitation course and transferable goal setting and goal management skills for long-term self-management. Clinician-related benefits included the fact that MyGoals can be incorporated into the current health care system, suggesting a good fit between MyGoals and the existing practice environment. Future studies can investigate these potential benefits and highlight them in the dissemination of MyGoals.

The occupational therapists reported MyGoals’ advantages over other existing methods, such as the COPM, again on both client- and clinician-related levels. First, the structured format of MyGoals, with the structured script and a goal pyramid to guide the formulation of life goals and building block goals, helps clinicians implement high-quality practice and develop the capacity to tailor their practice to the client. Second, MyGoals was seen as facilitating a holistic in-depth goal-oriented conversation by bridging the client’s life goal to their therapy goals. Other systems were viewed as more time efficient but less holistic, as suggested by the following participant quote: “I like [existing measure], but it doesn’t necessarily tie it all together to like the [MyGoals] life goal.” Last, MyGoals was considered more empowering and engaging for clients because it enables them to actively develop their goals and plans and to learn transferable goal setting and goal management skills. In particular, MyGoals’ ability to support plan formulation was acknowledged as a key benefit and comparative advantage over existing systems. These findings illustrate how MyGoals may solve two major research–practice gaps—(1) inadequate inclusion of all goal setting and goal management components and (2) poor client engagement—by providing clinicians with a convenient and concrete structure to ensure that all components are included in a way that promotes active client engagement (Kang et al., 2022; Stevens et al., 2013).

The occupational therapists’ feedback will inform future enhancements to MyGoals and its implementation. The main issue was the length of time it takes to deliver MyGoals. However, the occupational therapists acknowledged that although the increased time may hinder acceptability and feasibility, it likely leads to better client outcomes. They suggested that streamlining MyGoals and supporting its implementation (e.g., providing an electronic MyGoals manual or using Epic Systems software) may help mitigate this barrier by reducing the intervention and documentation time without compromising its efficacy. The occupational therapists also suggested capitalizing on the identified benefits and advantages of MyGoals (e.g., promoting usability) as well as providing implementation facilitators (e.g., continuing education to support documentation skill building).

This study has some limitations. One researcher was involved in all study processes, including clinician education, audit and feedback, and qualitative interviews. This frequent interaction could have created a potential bias in the participants. By having a coder (Chen) who was not part of the study process, we endeavored to minimize potential bias. In addition, we had a relatively small and homogeneous sample. The participants’ professional perspectives may have differed from those of clinicians with different backgrounds. Finally, implementation determinants can vary across contexts because of differences in implementation climate, health care policy, and so on. A larger study with a more diverse set of participants from different practice settings will help us further evaluate and optimize the efficacy and effectiveness of MyGoals.

This study assessed how MyGoals can support occupational therapists in planning and tracking goals with their clients, as well as their perceptions of its use. More research is needed to fully understand its effectiveness and how it can be integrated into daily occupational therapy practice. This study has the following implications for occupational therapy practice:

• ▪ Occupational therapists can explore the utility of MyGoals in their practice by observing how it complements their therapy sessions, gauging client reactions, and monitoring any shifts in client participation and the dynamics of therapist–client collaboration.

• ▪ If occupational therapists find that MyGoals is potentially helpful, they might start using some or all of its components in their daily practice.

MyGoals is an acceptable, appropriate, feasible, credible, and promising system to guide occupational therapists in implementing high-quality goal setting and goal management for adults with chronic conditions in community-based rehabilitation. The use of MyGoals may promote better goal setting and goal management, which in turn would support the overall rehabilitation process and ultimately improve the participation and health of clients.