Evaluative study

Clinical Rehabilitation
25(6) 501–514
A systematic review and synthesis ! The Author(s) 2011
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DOI: 10.1177/0269215510394467
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evidence behind patient-centred
goal setting in stroke rehabilitation

Sheeba Rosewilliam1, Carolyn Anne Roskell1 and

AD Pandyan2

Abstract
Objective: To map out from the literature the nature, extent and effects of application of patient-centred
goal setting in stroke rehabilitation practice.
Design: Systematic review.
Data sources: A search was conducted in the Cochrane (Wiley), AMED, Medline (EBSCO), Embase,
Sports discuss, Medline (Ovid) and CINAHL databases. Secondary search based on references from the
preliminary search was undertaken.
Review methods: Quantitative and qualitative studies that included aspects of patient-centredness and
goal setting in stroke patients from 1980 to June 2010 were collected. Studies were scrutinized for
relevance and quality based on published methodology. The findings were synthesized by aggregating
the themes from the qualitative studies and relating them to relevant findings from the quantitative
studies.
Results: Eighteen qualitative and eight quantitative and one mixed method study conducted in stroke
rehabilitation services ranging from acute to community rehabilitation were included. Themes that
emerged were related to perceptions of patients and professionals regarding patient-centredness, nominal
adoption of this concept, consequences of discrepancies in the perceptions and practice, related ethical
conflicts, challenges to application and strategies to improve its application. The effects of following
patient-centred goal-setting practice have been studied mostly with weak methodologies and studies
show some benefit with psychological outcomes.
Conclusion: Patient-centred goal setting is minimally adopted in goal-setting practice due to various
barriers. Since the effects of incorporating this concept have not been evaluated rigorously it is suggested
that further research is essential to investigate its effect on patient outcomes.

Keywords
Goal setting, patient-centred, systematic review, stroke
Corresponding author:
Sheeba Rosewilliam, School of Health and Population Sciences-
1
School of Health and Population Sciences-Nursing and Nursing and Physiotherapy, 52, Pritchatts Road, University of
Physiotherapy, University of Birmingham, UK Birmingham, Edgbaston B15 2TT, UK
2
School of Health and Rehabilitation, Keele University, UK Email: s.b.rosewilliam@bham.ac.uk

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502
Received: 4 February 2010; accepted: 24 November 2010
Introduction
Rehabilitation is a reiterative, active, educa-
tional, problem-solving process focused on a
patient’s behaviour (disability), and goal setting
is one of its central components.1 Goal setting is
defined as the process during which patient and
clinical members of the multidisciplinary team
make a collective decision, following an
informed discussion, of how and when to carry
out rehabilitation activities.2–7 If a clinician is
engaged in ‘patient-centred rehabilitation prac-
tice’ then the rehabilitation plan negotiated
during goal setting must relate to the patients’
expressed needs, values and expectations.8 The
approach to goal setting described above is dif-
ferent to the practice under a biomedical model
in which the decision-making process is often
unilaterally driven by clinicians who may not
be fully informed of an individual patient’s
needs.9–11 The likely outcomes of implementing
a biomedical model would be that the treatment
plans and outcomes of rehabilitation may not be
congruent between the patients and the profes-
sionals and as a result the patients’ expectations
are less likely to be met.10,12
The adoption of patient-centred goal setting
in neurological rehabilitation is complex. Two
main barriers to patient-centred goal setting
practice described in the literature are:
1. Patients may hesitate to participate in the
decision-making process and instead hand
over responsibility to experts. This can
happen if patients are either unable to partic-
ipate or perceive that they do not have the
competencies to actively engage with the
process.13,14
2. Clinicians may have reservations about
actively engaging patients in setting goals if
they perceive that patients are unable to par-
ticipate effectively due to their cognitive,
communication and expertise limitations.15–18
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Clinical Rehabilitation 25(6)
Despite these reservations, where profes-
sionals made efforts to involve patients in the
goal-setting process, the patients, recognizing
the importance of their involvement, were able
to contribute effectively.16,19,20 Increased patient
participation, information sharing and integra-
tion are thought to lead to better outcomes.21,22
Studies have demonstrated that goal setting (not
necessarily patient-centred) improved team
working,23 increased patient involvement in
their rehabilitation process,24 improved acquisi-
tion of motor skills,25 was helpful to assess reha-
bilitation outcomes and helped to meet
requirements set by professional organiza-
tions.3,7,26,27 Thus there is currently no evidence
as to why the patients’ views should not be
obtained to inform the rehabilitation process.
Stroke is a significant contributor to disability
and the ensuing financial burden affects the indi-
vidual, family and state.28–30 Improving out-
comes from stroke rehabilitation is a national
priority and identifying methods of achieving
this is a research priority. It can be hypothesized
that if person-centredness could be incorporated
in the goal-setting process for stroke patients
then the outcome of rehabilitation may signifi-
cantly improve.31–33
Thus the aims of this literature review are (a)
to explore and map out from the literature the
nature and extent of application of the patient-
centred goal-setting concept in current stroke
rehabilitation practice and (b) to examine the
evidence for any effects (outcomes) of applica-
tion of the concept.
Methodology
A systematic search (Appendix 1 – online only)
was carried out in Cochrane (Wiley), AMED,
Medline (EBSCO), Embase, Sport Discus,
Medline (Ovid) and CINAHL. The search
terms and strategy are attached as Appendix 1
Rosewilliam et al.
(online only). Search was conducted for the
period between 1980 and June 2010. The years
of search were limited since the concept of
patient-centredness was adopted by the physical
rehabilitation disciplines only during the
1970s.34 All citations were screened based on
title, keywords and abstract. Duplicates were
deleted. Secondary searches based on the refer-
ence list of articles from the primary search were
conducted and appropriate papers were identi-
fied. The above primary and secondary collec-
tion of literature was done by one researcher.
The remaining articles were screened for
inclusion based on the following criteria: (1)
human studies that had recruited stroke
patients, (2) used a patient-centred concept, (3)
studied the goal-setting process, (4) full peer-
reviewed publication and (5) published in
English language as translation facilities were
unavailable. Since case studies are not general-
izable35 those identified by the search were
not included in the review. All articles were
reviewed by one author and verified by one of
the other authors who was a subject expert.
Disagreements regarding inclusion were
resolved by consensus discussion.
Both qualitative and quantitative study
designs were included in the review to explore
the structures and mechanisms relevant to the
research question.36 A methodological quality
critique adapted from published literature37–39
was used to assess the quality of literature. The
aspects of methodological quality that were
scrutinized in the studies are listed as footnotes
in Tables 1 (qualitative) and 2 (quantitative)
(online only). The methodological critiquing of
the studies was done initially by one researcher,
cross-checked by one of the other two authors.
The findings from all qualitative studies were
extracted, summated into one document before
analysis. These findings were open coded, fol-
lowed by broader descriptive and interpretative
coding by the first author.38,40 The codes were
then refined by the two authors (SR and CR)
with respect to their context. Following this
the overarching analytical themes were derived
based on the similarities in codes and against the
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503
background of the review questions.
Aggregative synthesis to summarize and cluster
the coded findings of all qualitative studies
under the relevant themes was done by two
researchers (SR and CR).41 Any differences in
coding or derivation of themes were discussed
and modifications were made based on
consensus.
The results that were relevant to the review
question were extracted from the quantitative
studies (data extraction was carried out by SR
and verified by ADP). The quantitative research
findings could not be meta-analysed due to lack
of adequate numbers of randomized controlled
trials. Effect sizes were calculated where possi-
ble. The subject matter of the findings of the
quantitative studies were examined and based
on that these findings were placed under the
qualitative themes. This integration of quantita-
tive findings to the qualitative themes was done
by the first author.40,42 The other two authors
reviewed the matched themes and quantitative
studies with no disagreement. The integration
of results was undertaken to present a holistic
view of the issues relevant to the review
question.
Results
The search results, screening results and the final
numbers of studies included are presented in
Figure 1. None of the short-listed studies were
excluded on methodological quality grading as
only a few papers were available for the review
after the initial screening. Eighteen qualitative
studies, eight quantitative studies and one
mixed method study were included in the
review. The context of each study, the aims,
methods, samples, setting and methodological
quality have been summarized in Tables 1 (qual-
itative studies) and 2 (quantitative studies)
(online only). Data from the mixed method
study are appropriately presented in both
tables. The integrated list of derived qualitative
themes and corresponding quantitative studies
are presented in Table 3 (online only). The
data that contributed to the generation of
504 Clinical Rehabilitation 25(6)

Step-1
EBSCO Ovid Wileys
Amed 6 Embase 23 Cochrane
Medline 12 Medline 12 458
Sports Discuss 5 Psychinfo 3
Cinahl 26
Electronic Searches Total=545

Step-2
Titles screened, checked keywords, duplicates removed
Citations from e-search Total=126

Step-3
Abstracts collected, screened and articles collected
Articles from e-search Total=51

Step -4
Secondary literature search from reference list of e-searched articles
Citations from secondary search Total=81

Step-5
Abstracts collected, Screened and articles collected
Articles from secondary search Total=25

Step-6
Overall numbers of articles (51+25)=76
Articles screened for relevance to inclusion criteria and review question.
Reasons for non-inclusion: Commentaries, editorials, expert opinions or not totally relevant to the
research question.

Step-7
Validating inclusion of articles short listed=35
All articles reread and scrutinized for inclusion based on above criteria by the reviewers.
Approach Reviewer No. of Nos. agreed Nos. and Reasons for rejection
articles by
reviewed consensus
Quantitative SR 10 8 1 - description of a programme evaluation
ADP 10 1 - not explicit about the involvement of
patient-centredness.
Qualitative SR 24 18 3 - case studies, 1 - not specific to primary
CR 24 management, 1 - did not specify patient-
centredness within its exploration of goal
setting
1 - was found non-reliable in relevance to
the review question.
Mixed SR/ADP/CR 1 1

Final number of articles included in the review=27

Quantitative articles=8 Qualitative articles=18 Mixed methodology=1

Figure 1. Flow of studies in the search.

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Rosewilliam et al.
these themes are presented narratively in the fol-
lowing results subsection with the appropriate
source references identified.
1) Perceptions of patients regarding
patient-centredness in goal setting and
factors influencing it
Studies show that patients considered active par-
ticipation in goal setting as important12,43 since
patients expected that training, customized to
their personal goals, would change their life sit-
uation for the better.44,45 Patients had also per-
ceived that making progress towards personally
meaningful goals had been good for their self-
image and helped as a coping mechanism.46
Other non-specific reasons cited in the literature
are to avoid frustration, avoid embarrassment in
public, independence, not to be a burden to
others, pride, joy and to get back to work.47
Despite these strong motivations, the review
also revealed that patients had perceived that
they did not control the goals and their involve-
ment with goal setting was passive.48 Patients
had attributed this passivity to their limited abil-
ity to participate in goal setting (e.g. due to ill-
health), being unprepared to participate due to
limited information accessibility, and their
inability to accept their condition especially in
the early stages of the stroke.12 These patients
had also criticized the professionals and health
care system for being prescriptive and inflexible
with respect to treatment goal setting.12,48
The studies revealed that patients were of the
view that patient participation in goal setting
could be improved by processes such as formal
documentation of the patient’s views, empower-
ing key workers to be proactive, responding flex-
ibly to their changing needs and the use of
grading systems to measure their goal achieve-
ment.12,13,48 There is also some quantitative evi-
dence to suggest that when an explicit method of
patient involvement was used, such as the
Canadian Occupational Performance Measure
(COPM) or choosing goals from a given skills
list for therapy, patients chose skills that were
correlated to the regular use of those skills.24,47
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505
Use of an explicit method had also improved
patients’ perception of active participation in
goal setting.24
2) Professionals’ perceptions concerning
person-centredness in goal setting
The literature suggested that professionals lar-
gely believed that they were patient-centred.43,49
On occasions the clinicians perceived that they
had focused on the patient needs to a greater
extent than the patient’s family members.50
One study, which focused on occupational ther-
apists, reported that 80% (n ¼ 9) of the partici-
pants believed that they were patient-centred in
educating and involving patients in their goal
setting.43 Therapists perceived that the activity-
limitation goals they had set for the patient were
in line with the patients’ functional goals.51 They
had reported that patient-centredness in goal
setting would improve patient’s motivation,
effective use of time and contribute to holistic
planning.51 Despite these perceptions, the evi-
dence showed that the patients’ social and occu-
pational needs were not explicitly incorporated
into the treatment goals by therapists, thereby
reflecting a perceptual practice gap.51
Professionals ascribed various reasons that
could limit adoption of a patient-centred
approach such as concerns about future risks,
sociocultural barriers, environmental and
resource limitations.51–53 They implied that the
patients’ incapability to actively engage in the
process due to their lack of knowledge or exper-
tise, lack of confidence, unrealistic expectations
about future goals and their lack of cooperation
were the main barriers to involving them in goal-
setting processes.48,51–53
3) Status of patient-centredness concept in
current stroke rehabilitation goal-setting
practices
Among the various disciplines involved, occupa-
tional therapy had substantial literature on
patient-centred goal setting (15 of the studies
reviewed involved occupational therapists).
506
Different methods of goal setting were identified
from the literature and these are problem-
oriented, needs-based, impairment-based,
patient-centred, therapist-controlled and thera-
pist-led.49,51 Evidence from both qualitative51
and quantitative43,49 studies demonstrate that
current goal-setting practice is not largely
patient-centred. For example, while clinicians
perceived that their practice was patient-centred,
less than a quarter of the patient participants
assisted in goal-setting processes.43
Furthermore, although professionals were set-
ting goals and planning individual treatments,
most patients were neither given verbal nor writ-
ten information about the goal-setting process.49
It was not possible to identify an explicit
framework or process for a patient-centred
goal-setting process. In the existing stroke reha-
bilitation services, goal planning was mostly
done by the multidisciplinary team members
based on their assessment of the patient prob-
lems and resource available to the team. These
goals were then conveyed to the patient and the
family in a formal meeting.15
The identified barriers to patient-centred goal
setting can be summarized as:
1. Professionals’ avoidance of conflict in goal
setting situations by evading discussions rele-
vant to the patients perceptions of their goals
and by being totally prescriptive with the
patients’ goals.48,54
2. The family dynamics in situations where the
families had dominated this process for their
own interests, deviating the focus away from
the patient.50
3. Situations where patients were seldom con-
sidered as part of the multidisciplinary
team.15,48 Thus patient-centred goal setting
practices were seen to be constrained by the
system restrictions such as scarce resources
and professional attitudes.
Despite these barriers there is evidence sug-
gesting that patients had been able to put for-
ward or make choices about their personal goals
regardless of their condition duration.45,47,48,55
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Clinical Rehabilitation 25(6)
Patient involvement in goal setting may also be
influenced by the practice setting, with patients
from nursing homes and outpatients being more
aware of their goals and patients from outpa-
tient hospitals assisting better to formulate
goals.43
4) Consequences of discrepancies in
perceptions and practice of goal setting
The review revealed major discrepancies
between patient and professional, not just in
their perceptions regarding level of patient
involvement in the goal-setting process,43 but
also with regard to recovery and focus of reha-
bilitation. The clinicians had viewed recovery
from the point of the occurrence of stroke
while the patients had viewed it as an achieve-
ment of their pre-stroke status.54 As a result of
this perceptual difference, patients chose goals
that improved their level of participation, such
as mobility and social integration, in order to
recapture their pre-stroke status or adapt to a
new life situation.44,47,56 Meanwhile, majority of
the professionals’ goals for the patient were
focused on impairment and activity levels. For
example, professional goals were directed
towards achievement of independence in activi-
ties of daily living, locomotion and
communication.44,47,56
Although some professionals had indicated
that they were patient-centred, in actual practice
they had not been explicit with their goals
related to participation or had not delivered
interventions pertaining to the set goals.51,57 In
some instances professionals had suggested ways
to improve patient compliance that confirmed a
patient as a receiver and not as a collaborator.58
In situations where the patient’s goals were
unrealistic, resulting in breakdown of the thera-
peutic relationship, clinicians had attributed this
to the patient being stuck in the early stages of
grieving based on the ‘bereavement model’.55
These discrepancies in perception of illness
and recovery between the patient and profes-
sional evidenced in the literature seemed to
lead to conflicts not just in the goal-setting
Rosewilliam et al.
process but also impacted on other realms of
rehabilitation such as its delivery and the thera-
peutic relationship.
5) Ethical conflict
A study involving occupational therapists
revealed that the conflict in goal setting arising
due to the mismatch in values and priorities was
highlighted as a highly important dilemma
encountered in practice.59
6) Challenges to patient participation in
goal setting
In addition to the challenges highlighted in the
above themes the literature revealed multiple
other challenges to the employment of patient-
centredness in goal setting with stroke patients.
The difference in knowledge and expertise levels
between the patient and the profes-
sional15,17,48,53 that inhibited communication
and participation and professional behaviours
like protection of patients’ morale by physio-
therapists were also not conducive to involving
patients in determining their goals.17
Monaghan et al.60 suggest that the standard
goal-setting meeting which is held away from the
patient and with standard documentation is not
conducive to patient-centred goal setting. Other
inhibitory factors were limited time, presiding
professional routines and the single opportunity
to meet clinicians post discharge for secondary
risk management.15,17,51
Furthermore, the review suggests that psy-
chosocial factors such as the patients’ inability
to accept the occurrence of their stroke, depres-
sion, patients guarding against exposing their
inner self incompetence and not wanting to be
seen as moaners had hampered their participa-
tion in goal setting.12,17,51,53 Occasionally,
patient’s carers had set goals that moderately
deviated the focus away from the patient’s
needs and hence their involvement was consid-
ered as a potential barrier to patient-centred
goal setting.50 The factor that posed challenges
to patient involvement in goal setting that had
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507
been mentioned by both professionals and
patients was the stroke pathology with its
highly unpredictable recovery prognosis and its
effects, such as aphasia.13,51,54
7) Strategies to develop person-centredness
in goal-setting practices
The review of literature has revealed various
strategies that had been proposed by both pro-
fessionals and patients in order to meet the
National Service Framework for older people’s
(NSFOP) standard of person-centredness.7 The
literature proposes that a multidisciplinary team
approach involving the patient along with spe-
cialists such as speech pathologists improves dis-
cussion and documentation of patient goals.51,60
Therapists had suggested that patient and
family education regarding the pathology, pro-
cess of rehabilitation and goal setting, encourag-
ing patients to identify their goals would help to
establish realistic goals that are in line with the
patient’s expectations.51 These therapists
stressed skills such as listening skills, negotiation
skills, ability to adequately guide patients, abil-
ity to think laterally and seeking alternate meth-
ods of communication for patients with speech
problems in order to develop patient-centred-
ness in goal setting.51,58
Occupational therapists who sought to imple-
ment patient-centredness in goal setting high-
lighted that active decision making involving
patients needed to be pitched to their participa-
tion ability (graded decision making).52 This was
in line with the patients’ suggestion that their
participation be flexible according to their con-
dition and the goal setting be adjusted to their
changing needs.12
Professionals had recommended the use of
standard measures such as the Canadian
Occupational Performance Measure or wide
goal categories during goal setting to examine
all aspects of the patients’ requirements.54,61,62
Quantitative evaluation showed that the use of
the Canadian Occupational Performance
Measure to identify client-centred goals
improved opportunity for patient participation
508
in goal setting, their perception regarding partic-
ipation and ability to recall their goals.24,61–63
Once patient-centred goals were set and then
training, either conventional or innovative, tai-
lored to those goals was given, it led to short-
term improvement in activities of daily living,
better global outcome, better motor outcomes
(Wolf Motor Function Test – total time) and
better self-perceived performance and
satisfaction.61–64
To summarize, the literature around the
application of patient-centred goal setting,
though not of the highest quality, had investi-
gated prevalent practice, assessment protocols
and therapeutic input with the outcome mea-
sures being mainly psychological or disability
measures. Conflicts between the professional,
patient perception and practice in relation to
the adoption of the concept were brought to
light. The adoption of this concept in goal-
setting practice appears to bring positive psy-
chological benefits as reported by patients.
Discussion
‘Patient centredness is an overall philosophy in
which patients have an active involvement in
managing health care in partnership with service
providers who understand and respect their
needs’ (a quotation from a patient participant
in the study by Cott;12 the term ‘client’ in the
original definition was replaced by the term
‘patient’).
To our knowledge this is the first holistic
review to explore the evidence related to this
multidimensional concept of ‘patient-centred-
ness’ in goal setting with stroke patients.21,34,65
This study reviewed the literature to map the
nature and extent of the application of the
patient-centred goal setting practice in current
stroke rehabilitation and found that this was
uncommon, despite recommendations that this
be common practice.7,9,66,67 Despite indications
that patients could and wanted to be involved in
the process43,45,48,55 goal setting for stroke
patients was more clinician-centred, system-
centred or population-centred rather than
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Clinical Rehabilitation 25(6)
being patient-centred in the various aspects of
stroke rehabilitation.68 As a result, it was not
possible to map the nature of this process in
an explicit way. However, this review has iden-
tified significant barriers to patient-centred goal-
setting practice and methods that can be used to
incorporate patient-centred goal-setting
practice.
The review identified low-level evidence sup-
porting the claim that patient-centred goal-
setting practice may have a positive impact on
psychological outcomes. The benefits can
include improved self-efficacy, sense of auton-
omy,48 self-assurance,69 motivation,48,70 reduced
anxiety46 and empowerment leading to greater
competent participation in rehabilitation
efforts.47,48 There was no evidence indicating
that patient-centred goal setting in patients
who could participate in the process caused
harm to stroke patients or the service providers.
With regard to the adoption of client-centred
goal setting among professionals there seems to
be a reported disparity (i.e. 40% of physicians
(total numbers unspecified)49 and 80% (n ¼ 9) of
occupational therapists43 adopted it). The other
therapists and nurses were of the view that they
were quite limited in its adoption in their prac-
tice.15,48,51,54,59 However, this reported adoption
should be interpreted with caution, considering
the perceptual and practice gaps wherein what
the professionals perceived and reported was not
on par with what they actually applied in
practice.43
The person-centredness concept in goal set-
ting was observed in varying practice contexts
ranging from acute management to commu-
nity-based rehabilitation. Patients’ goals
included psychological and social perspectives
and were mostly aimed at improving participa-
tion levels. On mapping these findings onto the
International Classification of Functioning,
Disability and Health framework (ICF-WHO
2001)71 it is suggested that applying patient-
centredness is important not just at the point
of planning treatment and discharge but
throughout health care. Moreover the ICF71
framework rather than the biomedical approach
Rosewilliam et al.
could serve as an suitable base for constructing a
patient-centred rehabilitation programme due to
its inclusion of psychosocial constructs of
disability.1
The high volume of occupational therapy lit-
erature relevant to the patient-centredness con-
cept uncovered by the review is probably due to
the influence of the governing ideologies of the
profession.72,73 Moreover, the role of occupa-
tional therapists in the interface between hospi-
tal and community warrants a patient-centred
approach. Patient-centredness has also been
imbued into the occupational therapy profes-
sional culture as a part of educational training
better than in other health professions.73 Hence
the patient-centred practice principles from the
discipline of occupational therapy could be used
as a model to enable other professions to
develop patient-centred goal-setting practices.
Multiple barriers have been identified by the
review. The health care system was primarily
blamed for being too structured with dominat-
ing formal assessments which restricted explora-
tion of patient’s preferences and potential.74
This may result in reduced opportunities to
develop trust regarding the patients’ compe-
tence.75 It is important to explore whether
the system restrictions genuinely play such a
major role.
In view of the suggested sociocultural barriers
there is a need to set aside standard social and
cultural practices and explore patient prefer-
ences in ways that do not conform to the
system.74 For example, exploration of the
higher order values (values that are core to any
desire or need) that determine goals instead of
simply questioning for their goals46,47 could be a
better approach to determining patient-oriented
interventions. Yet another proposed strategy
from the literature is graded decision making
i.e decision making suitable to patient’s degree
of involvement at different points in time result-
ing in appropriately set goals which may
reduce patients’ passivity52,53 and improve
participation.
The professionals who shouldered a consider-
able portion of the responsibility to implement
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509
patient-centred goal setting10 reported difficulty
in exploring patient concerns53,74 and gathering
evidence on prognosis of the condition.76 They
therefore ended up sharing limited informa-
tion.77 Moreover, the professional’s personality
influences and limited contact time also impeded
the establishment of the therapeutic relationship
emphasized by Mead and Bower.65 The review
recommends that the responsibility for adoption
of patient-centred procedures must be shared
equally by patients and family.11 Additionally
education and support must be provided for
professionals in order to develop qualities of
empathy, respect for the wishes of patients and
to prevent feelings of professional threat during
the process of patient empowerment.16 It is also
noted that Rees et al.78 had recommended the
involvement of clinical psychologists to check
that goal-setting practices are patient-centred
and are based on psychological theories. Thus
the recommended professional education
regarding the process, barriers and proposed
strategies must draw on the skills of all profes-
sionals and be interprofessional so that the
approach is holistic rather than unidimensional.
This education and training could be incorpo-
rated within in-service training or as continuing
professional development programmes.
The other main barriers to patient-centred
goal planning identified are time and resources.
It is suggested that use of validated measures
from a standardized basket of measures pro-
posed by Turner-Stokes79 might be economical
in terms of time. However, the choice of out-
come measures from this basket must be
driven by the patient’s goals to make the goal-
setting process patient-centred and for measur-
ing the outcomes of this process. Measuring
qualitative outcomes based on patients’ experi-
ential goals can pose challenges for which an
open-ended flexible approach catering to per-
sonally meaningful goals has been suggested.36
On the other hand advocates of formalized
patient-centred goal exploration condemn such
informal interviewing as ineffective18 and sug-
gest the use of tools like life goals question-
naire,46 goal attainment scaling80 and the
510
Canadian Occupational Performance
Measure.24,63 Training and cost issues associated
with the Canadian Occupational Performance
Measure and issues of neglecting important but
immeasurable goals and instead setting unchal-
lenging goals associated with goal attainment
scaling (GAS) need to be contemplated.81
Measurement based on the patient-centred qual-
itative measures complemented with currently
used quantitative outcome measures could be
the means to a personalized yet valid approach
to evaluation of goal setting.
It is worth noting that all patients capable of
participating do not necessarily participate, with
some handing over decision-making responsibil-
ities to the health professionals. Judging the
emotional engagement with the goal discussion
can point to the level of involvement of the
patient and give directions for the professional
to pursue.82,83 Professionals need to educate
patients about the concept and the process of
patient-centred goal setting, provide clear infor-
mation regarding the condition, its prognosis
and time course in order to inculcate realistic
expectations.5,83 Time, facilitatory environment,
open communication and sensitivity to personal
factors and situations are essential to establish a
special therapeutic relationship involving
trust.18,53,69 These strategies may facilitate beha-
vioural change84 and improve participation in
goal setting.12 If all efforts to be inclusive of
patients within the goal-setting process fail
then the assumed best interests of the patient
might be considered. However, this leads to a
major ethical dilemma for professionals in reha-
bilitation practice, especially when conflicts arise
with the family in the process of setting goals for
the patient.
To summarize, it appears that the review
questions the adequacy of evidence to support
or disregard the use of the patient-centredness
concept. It appears that the recommendation
that goal planning involving the patient-centred-
ness concept is valuable is based rather on phil-
osophical arguments. Although this review did
not find evidence that can be used to suggest
changes in practice or policy, the findings have
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Clinical Rehabilitation 25(6)
been presented to improve understanding, high-
light problems and generate research ideas and
hypothesis for future research. It is a research
priority that the adoption of the concept is eval-
uated in stroke rehabilitation preferably with
phase I studies, prior to it being recommended
for practice.
Future research should concentrate both on
theory building, such as unpacking the complex-
ities, including the ethical issues embedded in the
patient provider relationship, and on developing
interventions to negotiate currently identified
barriers in the patient-centred goal-setting pro-
cess. Considering the influence of the health ser-
vice processes in patient-centred goal setting
future studies must evaluate self-referral system
models, staff training needs and empowered
patient roles within a stroke rehabilitation
team. Future research must also consider
implementation and evaluation of improved
information provision regarding patient-centred
goal-setting processes to the patient and the
professional and develop model programmes to
apply the concept. This would generate a sub-
stantial evidence base for this concept. It is also
proposed that rigorously generated evidence for
the concept in stroke settings could be adapted
to other settings.
The limitations of the review are that due to
the resource restrictions articles in languages
other than English were not included in the
review which might have resulted in failure to
capture some valuable information. In the pro-
cess of screening the studies it was decided to
include certain studies which mentioned inclu-
sion of stroke patients in their study population
even though they were not clear about the exact
number of stroke patients. Since the studies were
highly variable in their methods, hierarchical
status and quality, the balance between the
methodological grading and the quality assess-
ment for judging a study’s eligibility for inclu-
sion depended on consensus rather than
rigorous criteria. Although not all of the studies
were of the highest quality, this did not result in
exclusion of any of the short-listed articles by
consensus within authors, for the reason that
Rosewilliam et al.
stringent guidelines for qualitative research are
still evolving and therefore excluding evidence
from past decades based on current quality stan-
dards may have limited access to available
knowledge. It was not possible to report effect
sizes for all the included studies since they had
either not used an appropriate methodology or
they had not provided adequate statistical data
such as means, standard deviations, t-values or
degrees of freedom to calculate the effect sizes.
Therefore, in conclusion, since the conse-
quences of applying patient-centred principles
in goal setting have not been evaluated rigor-
ously in aspects other than for psychological
effects, its adoption in practice is not thoroughly
justified. This warrants further research on how
to operationalize the concept during setting
goals for the stroke patient and to build evidence
for the role of this concept in influencing the
outcomes that are relevant to the patient. Until
such research evidence is built the recommenda-
tions of the policies to follow this concept in
stroke rehabilitation remain anecdotal, ideolog-
ical and politically expedient.
Clinical messages
. Patients want flexible participation in the
process of goal setting. Two main strate-
gies to implement patient-centred goal set-
ting in stroke practice are (1) goal setting
by the multidisciplinary team members by
the patients’ bedside involving the patient
and (2) education and training of the
patient and professional regarding the
process.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or
not-for-profit sectors.
Competing interests
None.
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511
Note
References with asterisks are the papers that
have been reviewed.
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