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Goal setting &

action planning

Goal setting is one of the simplest yet most effective techniques you can use to assist behaviour change. 

Helping people make the day to day changes that are required to live well with a long term condition (commonly known as Behaviour change skills) are increasingly some of the most important skills of the healthcare professional in the 21st century. It requires us to work differently.

How will goal setting help?

Working with people to identify something they want to do is one of the simplest, yet most effective techniques we can use to improve communication and behaviour change. A systematic review on improving diet, published by the Agency for Healthcare Research and Quality in 2002, included goal setting in a list of a few intervention components shown to be associated with improved behavioural outcomes.​

"You can’t go back and change the beginning, but you can start where you are and change the ending." CS Lewis

A goal-oriented approach to making healthcare decisions, assessing outcomes and measuring success has several advantages:


  • It frames the discussion in terms of what the person wants to do rather than what might be generally accepted as what they should do.

  • It simplifies decision making for people with multiple conditions by focussing on outcomes that span conditions and aligning treatments towards common goals.

  • Goal-oriented plans enable people and their healthcare team, to discuss which health problems are important to them and decide on priorities in the context of how they can achieve what is important to them.

  • When priorities are known, people can collaborate with their healthcare team to determine steps to be taken towards achieving their goals and how progress can be monitored.

"If the patient's goal seems clinically useless, go with it anyway. Starting where the patient is at is more likely to ensure continued success then forcing them to start somewhere else." Mike Hindmarsh

Step 1

Discover motivation – what's important

There are questions that you can ask that will help identify why making a change is the right thing to do. Finding out what’s important to the person you are working with is the first step. This worksheet can help the structure of the conversation.

  • The goal should directly relate to what is important to the person you are working with.

  • The goal statement will, therefore, describe the motivation to follow the plan and make changes; it’s something the person wants to work towards.

Step 2

Thinking about change

Making changes can be hard, and to be successful people have to be confident that they are making the right change, for the right reasons. Focus on the benefits/gains rather than what they have to give up.

Help the person explore how they feel about making changes. This worksheet can help structure the conversation.


Step 3

Goal setting and action plan

Now that you understand what is important to the person and how they feel about making changes, you can now move onto setting a goal and making a plan. People who set goals related to what's important to them and motivates them are more likely to achieve them and make long-term changes. Encourage talk about what would make the goal more appealing. Try using this goal sheet.


Make an action plan  


Action plans are detailed descriptions of the actions a person will take towards achieving a goal. 

Follow the steps on the goal sheet. 

  1. Ask: “Is there something you would like to work on to help you achieve your goal?”

  2. Guide development of the plan by asking "What do you want to do? When will you do it? How often? Who can help me?"

  3. Gauge the level of importance and score on a scale of 1 to 10. If rated less than 7, adjust the goal to something that is more important to the patient/client.

  4. Assess Confidence. Again, score from 1 to 10 and adjust the goal to something that is 7 or more. A score of 6 or less suggests the goal is too hard. Likewise, if someone scores 10, then this goal is very easy for them and you could check if they wish to make it a little more challenging.  

  5. Arrange a short-term follow-up. A phone call, email, or text within one or two weeks of setting a new significant goal and change can make a significant difference to the likeliness of achieving it. Help the person problem solve if they are facing barriers or struggling to achieve their goal and action plan.

  6. Document goal and actions/tasks in patient/client’s notes and be sure to ask about it at the next visit.

Step 4


Arrange a short-term follow-up


Strengthen commitment to the goal and build on the action plan.

A phone call, email, or text within one or two weeks of setting a goal and action plan can make a significant difference to the likeliness of achieving it. Help the person problem solve if they are facing barriers or struggling to achieve their goal and action plan.

Build a support team

support network.JPG

Did you know?

People who are most successful at achieving change usually have support from others (friends and whānau). Encourage the person to think about who can support them.

Use this worksheet to help support the conversation here

There are also other tools: such as online blog sites and social network sites that you can suggest.

support team.JPG

Goal setting tips

  • Start small and keep it simple. Action plans should be SMARTER (specific, measurable, actionable, relevant, timebound, able to be evaluated and readjusted). The good news is that using the goal sheet ensures the person has a SMARTER goal. 

  • Pacing – avoid the ‘overactivity rest trap’ where a person gets enthusiastic and does too much on one day and feels exhausted the next and struggles to feel strong enough to try again. 

  • Make a plan for 'rainy days' or 'what if' something happens to get in the way.

  • Having difficulty working out what to do? Try problem-solving.


There are also many goal setting and action planning apps you can suggest.

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