Are SMART goals fit-for-purpose? Goal planning with mental health service-users in Australian community pharmacies (2024)

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Article history

Abstract

Introduction

Goal planning is regularly used to support service-users in changing their health-related behaviours [1]. Goal planning is a process whereby a health practitioner and service-user identify and agree upon a behavioural target that is worked towards over a specified period [2]. Goal planning improves autonomy and outcomes for service-users, directs the focus of assessments and interventions, and allows for evaluating outcomes and the documentation of service delivery [3]. Specific, meaningful, and challenging goal statements have been found to enhance performance and outcomes in various healthcare settings [4]. There is currently limited research on the best way to plan health goals, with few standardized processes for developing, recording, and evaluating goals [5].

The SMART model of goal planning recommends that practitioners consider several aspects of goals that promote positive outcomes [6], commonly that goals are ‘specific’, ‘measurable’, ‘achievable/attainable’, ‘realistic/relevant’, and ‘timed’ (SMART) [5]. The SMART method of goal planning was initially developed within organizational psychology to improve workers’ productivity [7]. Since then, SMART goals have been adopted in various fields, including sports, education, rehabilitation, and healthcare [4]. SMART goal formulations are recommended with specific goals providing guidance on actions needed to support achievement; measurable goals allowing the tracking of progress; achievability notes a service-user’s resources and barriers; relevance considers service-user’s preferences; and time-bound provides a clear target date for initiation and achievement of the goal [8].

Whilst the potential benefits of person-centred goal planning are recognized, research has identified that appropriate healthcare goal planning can be challenging and time-consuming, with goals often lacking specificity [9]. For example, allied health practitioners have experienced difficulty articulating service-user goals as specific and measurable statements [10], while service-users have reported not understanding the process or applicability of goal planning processes in healthcare settings [11]. This has resulted in calls for the use of formal goal planning procedures and guidance [12].

Much of the goal planning literature has focused on specific population groups, such as those with a traumatic brain injury or long-term health conditions [4], with less known about how planning can support brief health behaviour interventions [13]. Brief health interventions include time-limited, person-centred strategies that use motivational health promotion to target lifestyle habits and behaviour change [14]. As primary healthcare providers, community pharmacists are well-placed to provide brief health interventions during their encounters with regular service-users. This is particularly important for service users experiencing severe and persistent mental illnesses (SPMIs), given the illnesses’ social, occupational, and personal impacts and the increased likelihood of co-occurring physical health conditions in this population [15]. Goal planning, as a component of brief health interventions, is increasingly being incorporated in community pharmacist-led services supporting service-users experiencing long-term conditions [16]. However, little is known about what aspects of goal planning are most important in supporting health behaviour changes [13].

Therefore, this study sought to investigate how community pharmacists operationalized SMART goals during a brief wellbeing intervention with service-users experiencing SPMIs, particularly the quality of the documented goals, aspects of SMART goal method utilized, and which elements were included less often.

Method

Study design

Data were drawn from the PharMIbridge Randomized Controlled Trial (RCT), in which pharmacies were assigned to the intervention group (IG) or the comparison group (CG) (standard in-pharmacy medication review service). IG pharmacists provided a 6-month, person-centred, flexible, community pharmacy-based intervention with service-users experiencing SPMIs [17]. The intervention was designed to review and address service-users’ health concerns, particularly those related to physical health and medicine-related problems, and provide a brief goal planning intervention as part of a broader multicomponent intervention [17]. The RCT was undertaken between 2020 and 2021, recruiting IG pharmacies (n = 25) in rural, regional, and urban areas across four regions of Australia. Pharmacy staff recruited service-users aged 16 years or over who had been using antipsychotic and/or mood stabilizer medicine(s) for SPMIs regularly for the 6 months before recruitment, who had unmet physical health concerns, and/or were at risk of or already experiencing medicine-related problems. Ethical clearance was obtained from the Griffith University Human Research Ethics Committee (HREC/2019/473).

Intervention pharmacists received training comprising the Blended-Mental Health First Aid (B-MHFA) for the pharmacy course [18], including online self-paced modules and a half-day face-to-face session with a licensed instructor, followed by a one-and-a-half-day workshop that provided opportunities to participate in and observe simulated patient role-plays and engage in debrief discussions with people with lived experience, as well as, training on the mind-body interface; complex psychotropic medicine use; managing physical health concerns; communication, motivational interviewing, and goal planning [19]. During the training, there was a focus on understanding the lived experience of mental illness, exploring strategies to promote behavioural change and improve physical health, and a collaborative strengths-based approach to goal planning. Training materials were co-delivered by a pharmacist and a person with lived experience of mental illness who formed mentor pairs in each trial region and continued to support the pharmacists throughout the delivery of the intervention. The 2-hour goal training module centred on the transtheoretical stages of change model [20], motivational interviewing [21], and how to develop SMART goals [5]. This module provided information on how to conduct goal planning conversations, identify actions, and complete goal planning worksheets, providing a number of SMART goal examples. No measurement of the pharmacists’ confidence or experience in SMART goal planning and documentation was undertaken prior to the intervention.

Goal planning process

An ‘Initial Health Review’ was undertaken with pharmacists supporting each service-user in completing screening tools to identify health concerns, aiding the direction of goal planning. Service-users and pharmacists collaboratively identified concerns regarding physical and psychological wellbeing and medicine use before co-designing individualized goals and goal plans. All data were recorded in PharMIbridge-specific modules integrated into pharmacy clinical practice software (GuildCare NG^TM). Pharmacists were asked to document the key issue and how the goal would be achieved. Pharmacists followed up with service-user participants at tailored intervals over 6 months to review and adjust or create new goals as required. Goals were recorded at each consultation.

Measures

The SMART Goal Evaluation Method (SMART-GEM) tool was used to assess whether the goals documented by pharmacists, in collaboration with service-users, met the SMART criteria: specific, measurable, activity-based, and included information about review and time-frame [22]. Bowman [22] argued that assessing whether a documented goal is achievable/attainable or relevant/realistic required knowledge of the service-user’s circ*mstances and context and, as such, could not be accurately assessed by reviewing documentation alone. Instead, activity-based and review were included to reflect the importance of important goal aspects including clearly specifying behaviours and providing regular feedback [23]. The SMART-GEM does not assess how the goals were determined but instead assumes that a clear understanding of key needs and a collaborative approach to goal planning is undertaken [24].

SMART-GEM is a standardized tool designed to evaluate SMART goals in clinical and research settings objectively [22]. SMART-GEM has been assessed within a physical and neurological rehabilitation setting as having good construct validity and inter-rater reliability on total scores [22]. The tool provides a framework to assist health practitioners in writing SMART goals and sets specific criteria for evaluating written goals [10]. Each of the five domains corresponding to the SMART acronym has a set of criteria (Table1) to reflect clinically useful goals and to allow for objective auditing of written goals [24]. Each criterion is scored with a ‘1’ (goal meets the criteria) or ‘0’ (goal does not meet the requirements). These scores are then totalled to a possible final score of ‘8’, with a score of ‘8’ assessed as an ‘excellent’ goal, ‘7’ as good quality, ‘6’ as ‘average’, and ‘5’ or less classified as ‘poor’ quality goals [24].

All goals documented during the PharMIbridge intervention were evaluated using the SMART-GEM tool. Before undertaking data analysis, two members of the research team (VS and SS) scored the practice goals (n = 10) provided in the SMART-GEM manual [24], discussing any differences in interpretations and clarifying discrepancies with the manual’s provided answers. Next, PharMIbridge goals were downloaded from the software into an Excel spreadsheet and scored. This included two preliminary scorings of ten goals by the same two researchers, comparing the scores and discussing discrepancies until both scorers were comfortable in applying the tool in the same manner. All goal-related information obtained during the PharMIbridge intervention (key issue, goal, and action plan) was included in the scoring. A further 10 goals were independently scored, with good consistency achieved. VS then scored each PharMIbridge goal individually using the SMART-GEM score sheet [24]. SM completed a quality review of 25 goals (5%) with only three minor discrepancies on individual items identified, not impacting the overall grading of those goals.

The goals were also categorized utilizing an existing taxonomy [25] into five domains describing the content of goals (Table2).

Data analysis

The total score of the SMART-GEM scale was used to measure the quality of goals. The normal distribution of the data was tested using the Shapiro-Wilk test. The overall quality of goals was compared across goal domains using the Kruskal-Wallis H test. Data were summarized using mean and standard deviation, or median and interquartile range (IQR, 25th–75th percentile) for continuous variables, and number and percentage for categorical variables. All analyses were performed using SPSS version 29.

Results

All 512 documented goals from all intervention group service-users (n = 156) were evaluated using the SMART-GEM method. Goal data were available for all participants who had received the PharMIbridge intervention. The mean number of goals for each participant was two (range one to five).

Participant characteristics

Service-user participants were typically born in Australia (n = 144, 92.9%), female (n = 84, 53.8%), with a mean age of 48.1 years (SD = 14.9). Additionally, they lived in non-metropolitan locations (n = 100,64.1%), were unemployed, a student, volunteer, or receiving a pension (n = 113, 73.1%), and self-reported living with two or more mental health (62.0%) and physical health (68.4%) conditions.

Goal content

Based on a published goal taxonomy [26], all 512 goals were mapped into five pre-specified domains (Table3). Just over half of the goals were about lifestyle and wellbeing (n = 276). The second most common goals were related to managing physical health conditions (n = 77). Only 11.9% of goals (n = 62) were mapped to the ‘use of medicines’ domain. Additionally, fewer than 10% of the goals (n = 50) were related to managing mental health conditions.

Goal quality

All goals evaluated were classified as poor-quality goals (receiving a total SMART-GEM score of 5 or less). A Shapiro-Wilk test identified a non-normal distribution (P < 0.001) of goal quality data, with a median of two and an IQR of one to three (25th-75th percentile). Overall, 81.0% (n = 417) of the goals scored two or fewer, with less than 1% achieving a total score of five (n = 4) and six goals (1.2%) receiving a ‘0’ (Fig.1).

A Kruskal-Wallis H test showed that there was a statistically significant difference in SMART-GEM total scores across the five domains of goals χ²(4) = 35.303, P < 0.001 (Fig.2). While the median total score across all domains was a score of 2, lifestyle and wellbeing goals had a larger variance, with scores ranging from 0 to 5 (IQR 2.0).

The documented goals contained information about an observable behaviour and/or intervention (71.3% and 86.3%, respectively). In particular, goals related to satisfaction with life (44/47, 93.6%) were most likely to contain information about an observable behaviour (Table3). Less than 25% (n = 125) of goals included information on how goal achievement would be measured or the criteria for an acceptable standard of outcome performance. Of these goals, lifestyle and wellbeing goals were more likely to meet the measurement criterion (n = 119). Twenty-one of these goals included information about both measurement of goal achievement (how measured) and an acceptable standard of achievement (measurement criteria).

Given that the goals were collaboratively developed between pharmacists and service-users, only 67.7% of goals related to the use of medicines included an observable behaviour. However, 95.2% of these goals contained details regarding intervention or action. Additionally, most documented goals, across all domains, failed to include any written evidence of goal monitoring processes, such as information about planned reviews or time-frames for goal achievement.

Discussion

Statement of principal findings

The evaluation of goal quality undertaken in this study using the SMART-GEM tool demonstrated that the goal data reported by community pharmacists ranked poorly in meeting the SMART guidelines for goal statements, with all goals classified as poor quality and 6 of the 512 goals assessed as not meeting any of the SMART criteria. However, most goal statements contained some information about specific goal-directed behaviours and actions, in particular those related to satisfaction with life and lifestyle and wellbeing.

Strengths and limitations

Given this study’s exploratory nature, the SMART-GEM tool and manual were used to ensure rigour in our findings. A large variation in how pharmacists documented the goals was noted, which sometimes challenged the application of the evaluation tool and may have led to errors in scoring. Additionally, the SMART-GEM tool was developed by allied health clinicians and has been trialled in clinical settings [22]. To our knowledge, the SMART-GEM tool has not been used to assess the quality of goals developed within community pharmacy settings or with service-users experiencing SPMIs. This raises questions regarding the applicability and validity of the SMART-GEM tool within this setting. While the intervention was person-centred, it is unclear from the data how service-users were engaged in goal identification and planning, whether they were ready to develop SMART goals, and the level of pharmacists’ skills in SMART goal planning. In addition, this evaluation identified that there was a lack of detail in the recording of the majority of goals. This may be a documentation or recording quality issue rather than an issue with the goal planning process’s quality.

Interpretation within the context of the wider literature

Results from this study identified that goals developed during a brief wellbeing intervention appeared to contain less detail than the recommended traditional SMART goal planning format. While this study did not explore why the goals failed to meet the SMART criteria, factors such as the setting in which goal planning occurs and the service-user population participating in goal planning have been found to influence how goals are prioritized and documented [27]. Much of the research regarding the use of SMART goals has been undertaken in clinical settings, often focused on supporting service-users to overcome functional impairments rather than change health behaviours [28]. Less is known about how SMART goals are being incorporated into brief health inventions in primary care and community-based settings. For example, this study identified that very few goals developed in community pharmacy settings contained information about the specific conditions (0.8%) and context (2.7%) of the goals. This may have been due to an assumed or shared understanding of the conditions (e.g. service-user performs the activity independently) and context (e.g. home environment, local community). These considerations may not be seen as important to include when documenting goals within community settings.

Of interest is the limited number of goals that contained measurement information. Without a measurement component, it is difficult to measure outcomes and demonstrate an intervention’s effectiveness. Within this study, the goals most likely to contain measurement were related to lifestyle and wellbeing. It may be that these goals included behaviours or outcomes that were easier to measure (e.g. weight change, exercise duration) compared to other goal types (e.g. those related to mental health status, relationships, or pain) which may be more challenging to measure [10]. This could be due to the pharmacists’ lack of confidence in planning goals outside their usual scope of practice or their general lack of knowledge and experience in developing SMART goals.

While goal specificity has been previously explored in various healthcare settings [16], studies tended to use researcher-developed, non-validated audit tools, preventing a comparison of results. The one identified prior study using the SMART-GEM tool examined allied health clinicians’ goal quality and found similar results for goals planned before the clinicians underwent further SMART goal training [10]. Before implementing the intervention, the PharMIbridge pharmacists received training about SMART goals but had limited opportunities to practice and did not receive any feedback on the documented goals. It is, therefore, difficult to determine the level of knowledge and confidence that pharmacists had in using the SMART goal method or if goal quality would have improved with ongoing feedback. Several studies have suggested that training, practice, and ongoing support are needed to assist health practitioners in creating specific and meaningful goals [5, 10].

Implications for policy, practice, and research

Studies have identified that healthcare practitioners find it challenging to apply SMART goals to the broader life goals often prioritized by service-users [29]. Service-users have reported that SMART goals do not always accurately capture their personal preferences or reflect the complexity of their everyday lives [11]. Therefore, it can be challenging to transform complex and varied needs into measurable, specific, realistic goals during brief interventions. Additionally, goal planning and commitment facilitate motivation to make health changes, and it is unclear if the use of SMART goals during brief interventions accurately reflect or incorporate service-users’ longer-term goals, which can be more personally meaningful and motivating. This is an important consideration for including goal planning in short-term interventions focused on initiating behaviour changes rather than when focused on the service-users’ long-term trajectories.

Within mental health service delivery, goal planning is recognized as an integral component of recovery, providing a means to explore and achieve aspirations for the future and promote hope and personal meaning [30]. It is unclear if goal planning needs for service-users experiencing SPMIs differ from those with other health conditions. Given the limited research regarding the use of SMART goal planning within mental health recovery, further research is needed to identify which elements of the SMART acronym are most suited to supporting service-users experiencing SPMIs in achieving their desired outcomes when receiving support in community-based, primary care settings.

Conclusion

This study provides insights into the quality and documentation of goals co-designed between community pharmacists and service-users experiencing SPMIs during a brief wellbeing intervention. Whilst SMART goals are recommended for use in brief health interventions, the findings from this study demonstrated that in practice, goals documented by PharMIbridge community pharmacists did not meet the SMART criteria. Further research is needed to determine which elements of the SMART criteria are most important in supporting positive health behaviour changes for service-users participating in brief interventions in primary healthcare settings. Additionally, further investigation is needed regarding the training and types of resources that could support primary healthcare practitioners to incorporate goal planning in brief health interventions.

Acknowledgements

The PharMIbridge RCT was developed in partnership with The Pharmacy Guild of Australia, the Pharmaceutical Society of Australia, Griffith University, and The University of Sydney. The research team would also like to thank the participants in our study.

Author contributions

Amanda J. Wheeler (Conceptualization, Investigation, Methodology, Supervision, Writing—review & editing), Claire L O’Reilly (Conceptualization, Supervision, Writing—review & editing), Sara S. McMillan (Conceptualization, Investigation methodology, Supervision, Writing—review & Analysis), Sarira El-Den (Conceptualization, Supervision, Writing—review & editing), Victoria Stewart (Conceptualization, Data curation, Formal Analysis, Writing - original draft), Jie Hu (Conceptualization, Data curation, Formal Analysis, Writing—review & editing), Jack C. Collins (Conceptualization, Data curation, Formal Analysis, Writing—review & editing).

Conflict of interests

No known conflicts of interest.

Funding

Data collected for the PharMIbridge project, from which data from this study was used, received grant funding from the Australian Government Department of Health and Aged Care. This study was undertaken as part of a doctoral thesis (VS) supported by a Griffith University scholarship. The researchers were independent from the funder. This article contains the opinions of the authors and does not in any way reflect the views of the Department of Health and Aged Care or the Australian Government. The funding provided must not be taken as endorsem*nt of the contents of this paper.

Data availability statement

The datasets generated during and/or analysed during the current study are not publicly available due to the sensitive nature of the results, but deidentified summaries of the data may be available from the corresponding author on reasonable request.

References

Author notes

Handling Editor: Ms. Linda Graudins

© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Quality in Health Care.

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