Frequently Asked Questions

Do goals need to be SMART?


People’s recovery pathways are often complex, unpredictable and influenced by unforeseen circumstances or events.

This makes it very difficult to agree goals at the outset that are Specific, Measurable, Achievable, Relevant and Timed.

G-AP goals should ALWAYS be:

  • Relevant to the person’s individual needs, preferences and priories
  • Described in the person’s own words
  • Focus the person on what they want to achieve
  • Focus the team on providing person centred rehabilitation input

Being Specific, Measurable, Achievable and Timed is less important and can result in staff centred rather than person centred goals.

G-AP goals can be adjusted and/ or replaced with suitable alternatives as the process unfolds – so being SMART at the outset is not necessary.

Remember, we can learn just as much from setbacks as we can learn from successes.

Setbacks can help the person to understand and accept their limitations and to consider adjusted or alternative goals.

Do people have to come up with their own goals and plans to make them person centred?


Some people find it really difficult to come up with goals and plans; others will know exactly what it is they want to achieve.

Some people find it reassuring when the staff member suggests goals and plans, especially if they believe they are the experts and are in a good position to advise.

Goals and/ or plans can be suggested by the person, staff member or carer when using G-AP.

It doesn’t matter who comes up with them, as long staff work in partnership with the person and everyone agrees on the goal(s) and plan(s).

Partnership working is like moving back and forward along a continuum whilst always seeking agreement and maintaining a person centred approach.

Where you are on the continuum will be influenced by various factors including: the person’s beliefs, stage of recovery and their goal setting experience.

What if the person comes up with goals that are ‘unrealistic’?


This is something all staff find challenging at times.

There are lots of issues to consider, for example …

Gauging whether a goal is achievable or not is challenging:

  • Sometimes it’s difficult to gauge whether a goal is unrealistic or not
  • Some people surpass our expectations
  • Others don’t do as well as we thought they would
  • There is not always evidence available to inform our recovery predictions

Staff members and the people they work with think about goals from different perspectives:

  • The person may be dealing with a new diagnosis or change in their health condition; it may be difficult for them to think ‘realistically’ about future possibilities because they don’t have the experience (yet)
  • Staff might better understand ‘realistic’ future possibilities; but they will not fully understand the person’s coping skills, mindset or what resources they have available to help them. Therefore, they too might find it difficult to gauge whether a goal is achievable or not
  • Goals reflect people’s hopes and aspirations about their future
  • Hope is really important to sustaining our emotional wellbeing and motivation
  • Even if people come up with goals that are at odds with what you think is achievable, we have to be careful not to dismiss them as “unrealistic”
  • We can offer people advice based on our experience and knowledge to help them consider their goals
  • We can also support them to consider barriers that may get in the way of achieving goals
  • But this has to be balanced with maintaining a positive approach and hope for the future

The G-AP process supports different pathways to goal attainment:

  • Using G-AP, you can start off with a goal that you are concerned may not be realistic knowing that the process will support ongoing appraisal, feedback and decision making
  • This will create opportunities for you to support people to adjust goals or to disengage from those proving unattainable and re-engage with suitable alternatives

All of these issues should be considered throughout the G-AP process. Every person will need an individual and tailored approach. Maintaining a positive approach and hope for the future needs to be factored in.

What if the person isn’t confident that they can complete their action plan?

If the person isn’t confident they can complete their action plan (score of less than 7 on a 10-point visual analogue scale) it should be discussed and possibly modified:

  • Is it too difficult? If so, can it be made easier?
  • Have all the barriers been considered? If not, are there other barriers that need to be considered?
  • Is the coping plan effective? If not, is there a different coping plan that would work better?

Ask the person to rate their confidence to complete the revised plan.

Only agree the plan when you are both confident it can be completed. If the person is not confident they can complete the plan, the chances are they won’t.

Is it important to appraise the outcome of every action plan?


It’s important for the following reasons:

  • G-AP aims to help the person to achieve their personal goals
  • By appraising the outcome of every action plan, you are collaboratively checking if they are “on track” or “not on track
  • If the person is on track – you are creating on-going opportunities for positive feedback that will act to boost their confidence and motivation.
  • If the person is not on track – you can support them to understand their limitations and (if necessary) make timely adjustments to their plans and/ or goals.

When is it OK not to agree to set a goal?

Sometimes there are good reasons why staff are unable to agree on a person’s goal.

For example, if there are:

  • Safety issues (e.g. supporting a person with poor safety awareness & balance to climb a ladder up to their roof)
  • Legal issues (e.g. supporting a person to drive when been advised not to by the DVLA)
  • Ethical issues (e.g. supporting a person with a gambling addiction to go to the betting shop)

If you find yourself in this situation, it’s important to acknowledge the person’s goal and then explain why you cannot support them to pursue it. You can then check the person understands the reasons why and give them an opportunity to ask questions.

Should G-AP be used with everyone?

Our research has shown that G-AP may not be helpful if the person …

  • Is unable to identify any person goals (even with support)
  • Has very straightforward goals that can be met quickly and easily (e.g. if simple provision of a walking stick will allow them to meet their only goal of walking confidently outdoors)
  • Is feeling so emotionally overwhelmed that thinking about ‘where they are at’ and ‘where they would like to get to’ is likely to be unhelpful or counterproductive
  • Is medically unwell/ unstable

If possible, it is important to go back and ‘check in’ with the person at a later date to see if the timing is better for them to get involved in the G-AP process.

Useful References


Barnard RA, Cruice MN, Playford ED. Strategies Used in the Pursuit of Achievability During Goal Setting in Rehabilitation. Qualitative Health Research. 2010;20(2):239-250. doi:10.1177/1049732309358327


Scobbie, L. et al.  (2021) Goal attainment, adjustment and disengagement in the first year after stroke: A qualitative study, Neuropsychological Rehabilitation, 31:5, 691-709, DOI: 10.1080/09602011.2020.1724803. Access here:


Scobbie, L., et al. Implementing a framework for goal setting in community based stroke rehabilitation: a process evaluation. BMC Health Serv Res 13, 190 (2013).


Snyder, C. R., et al. (2006). Hope for rehabilitation and vice versa. Rehabilitation Psychology, 51(2), 89–112.


Scobbie, L. et al. (2021) Goal adjustment by people living with long-term conditions: A scoping review of literature published from January 2007 to June 2018., Neuropsychological Rehabilitation, 31:8, 1314-1345,


Bright, FAS. Et al (2013) Hope in people with aphasia, Aphasiology, 27:1, 41-58,


Bright FAS, McCann CM, Kayes NM. Recalibrating hope: A longitudinal study of the experiences of people with aphasia after stroke. Scand J Caring Sci. 2020 Jun;34(2):428-435. doi: 10.1111/scs.12745.


MEANING as a smarter approach to goals in rehabilitation (2015) in Rehabilitation Goal Setting: Theory, practice and Evidence, 2015. Ed Siegert & Levack; CRC press, Taylor Francis.


Barnard RA, Cruice MN, Playford ED. Strategies Used in the Pursuit of Achievability During Goal Setting in Rehabilitation. Qualitative Health Research. 2010;20(2):239-250. doi:10.1177/1049732309358327


Leeson R, Collins M and Douglas J. Finding Goal Focus With People With Severe Traumatic Brain Injury in a Person-Centered Multi-Component Community Connection Program (M-ComConnect). Frontiers in Rehabilitation Sciences. 2:786445.