Contributions to the literature’ section.
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This study adds an Australian context to the current literature examining barriers and enablers to implementing goal-setting practice in rehabilitation services. Furthermore this study describes the challenges faced by clinicians working in varied case mix rehabilitation services.
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This study describes a comprehensive approach to goal-setting intervention development and implementation that can be replicated in clinical practice.
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This research is based on a theoretical conceptual framework and has led to development of six interventions aiming to comprehensively address the active ingredients influencing goal-setting practices in rehabilitation services.
Background
Methods
Study design
Study sites
Phase 1- identify barriers and enablers—methods and results
Participants
Procedure
Data analysis
Results
Site | Disciplines represented | Sex | Average Age | Average years of experience in the profession | Average years of experience in rehabilitation |
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Site 1 (n = 7) (n = 1 missing data point) | Dietetics, Nursing, Occupational Therapy, Physiotherapy, Rehabilitation Consultant, Speech Pathology | 100% female | 34.17 (± SD 6.40) | 11.17 (± SD 6.55) | 7.17 (± SD 4.31) |
Site 2 (n = 9) (n = 1 missing data point) | Neuropsychology, Nursing, Occupational Therapy, Physiotherapy, Rehabilitation Consultant, Social Work, Speech Pathology | 100% female | 41.38 (± SD 9.52) | 16.88 (± SD 9.40) | 12.63 (± SD 8.55) |
Site 3 (n = 7) | Neuropsychology, Nursing, Occupational Therapy, Physiotherapy, Rehabilitation Consultant, Speech Pathology | 29% male | 37.43 (± SD 9.88) | 13.71 (± SD 9.34) | 9.86 (± SD 6.23) |
71% female | |||||
Site 4 (n = 13) (n = 2 missing data points) | Allied Health Assistant, Dietetics, Neuropsychology, Nursing, Occupational Therapy, Physiotherapy, Speech Pathology | 8% male | 38.82 (± SD 10.41) | 12.18 (± SD 10.82) | 7.82 (± SD 5.74) |
92% female | |||||
Site 5 (n = 8) | Dietetics, Occupational Therapy, Physiotherapy, Social Work, Speech Pathology | 12.5% male | 41.75(± SD 9.62) | 17 (± SD 10.44) | 12.52 (± SD 10.44) |
87.5%female |
Active ingredients | TDF domain | Key themes | Quotes |
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Teamworking | Knowledge | Lack of understanding of a client centred goal-setting focus (.b) |
“How do we separate out the individual discipline goals? For example, you know, be able to pronounce this, or be able to match words to pictures with 50 per cent accuracy … How do we distinguish from that from the shared goals?” (Site 3)
|
Skills | Skills to set rehabilitation goals with clients outside of discipline skill sets (.b) |
“I could set a broad goal, but it probably wouldn’t be… I wouldn’t have enough insight to have a SMART goal for that.” (Site 3) | |
Social and professional role and identity | Absence of the nursing role (inpatient rehabilitation) (.b) |
“we don’t get included…in the MDT, or the allied health goal-setting,” (Site 1) | |
Environmental Context | The need for consistent processes (a) but the want for flexibility (.b) |
“I think the challenge is always trying to find one process, and one tool that everyone is going to use… but if we really want to be person-centred, then we need to be flexible about how we do our goal-setting” (Site 4) | |
The case conference forum (.a) |
“case conference is a good opportunity where we come together and feedback to each other about what goals we’ve been working at, and then formulate a sort of more shared goal” (Site 1) | ||
Electronic and paper-based record keeping systems |
“I spend more time doing paperwork than I actually do client work” (Site 5) | ||
“then every outcome measure is…put into a database and there’s a lot of crosschecking” (Site 5)
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Beliefs about consequences | Lack of client involvement in case conference (.b) |
“it’s fragmented though, through EMR [electronic medical record]…plus each therapist will write up what their goals are, so there’s no actual framework where they’re all in one” (Site 3) | |
“we probably don’t—in this service—have a platform where we all get together as an MDT with the patient and actually look at their goals and how they’re progressing” (Site 3) | |||
Shared decision-making | Knowledge Skills | Clinicians skills to facilitate goal-setting interactions (a/.b) |
“potentially for junior staff, they’re so overwhelmed… learning their discipline specific stuff, that to think broader can be quite hard” (Site 1)
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“I think, a big challenge for our team in particular, is that level of skill and experience with doing that very specific goal-setting and being able to break it down with the patient engaged in that process and show them how it all connects, and coming up with very specific goals that are still their goals” (Site 2)
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Beliefs about consequences | Timing of goal-setting interactions (possibly too early inpatient rehabilitation) (.b) |
“We’re still grappling with, okay, this is what they’ve done in a few days since their stroke, we think this is what they might get to based on their type of stroke and experience …So if we’re grappling with it and we’re expecting them to have some kind of concept, it’s really hard to—to do it so early” (Site 3) | |
Beliefs about capabilities | Clinician challenges with those who have cognitive impairment or who are not ready to goal set (.b) |
“their cognition means that they are … insightless to their impairments and function so it ends up being therapist directed” (Site 1) | |
Environmental context and resources | Time taken to conduct goal-setting interactions (b) Service setting context (.a) |
“the amount of time it takes to do goal-setting well, which, here [community rehabilitation] … it’s a bit better because you can actually say, “Okay, I need to actually make an appointment time to do this. Whereas in inpatients, you’re lucky if you get two minutes to spend on goal-setting, realistically” (Site 4)
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Using measurement tools and questionnaires (.a) |
“others who maybe are having a bit more trouble really getting out clear goals, or coming up with goals, then I might switch to a tool like the COPM or something, to help.” (Site 4) | ||
Meaningful and specific goals | Social influences | Clinicians obligation to set goals relevant to the role of the service (.b) |
“Or goals that are appropriate to our service, is harder to extract than just personal goals” (Site 2)
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“I think there can be some conflict between the patient’s own goals that are maybe set spontaneously without much guidance from therapists, and then from the service perspective” (Site 2)
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Beliefs about consequences | Clinicians beliefs that goal-setting needed to be realistic to avoid client disappointment (.b) |
“cause otherwise you’re setting them up to fail” (Site 1)
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“it’s that fine line between them being something that the patient wants and something that we think is achievable” (Site 1) | |||
Environmental context and resources | The differences in goal focus between inpatient and community rehabilitation settings (.b) |
“person centred goal-setting is this big board idealistic thing that sometimes we maybe struggle to achieve in the setting, because the setting dictates what you work on” (Site 1) | |
Action planning and review | Knowledge | Understanding the differences between goals and actions or staff task lists (.b) |
“normalising their calcium, normalising their potassium, normalising whatever. Getting them pain-free. Getting on top of their pain is a goal” (Site 3)
|
“we’ve got a whole pile of participation goals, activity goals, impairment goals and there’s some education goals or information, like information about EPOA [enduring power of attorney] and wills we pop … that can be a goal as well” (Site 5) | |||
Memory attention and decision-making | Goal review and feedback was often ‘forgotten’ (.b) |
“people are generally quite good at going and getting the initial goals off people, but the review process of reviewing the goals and things, I don’t think happens consistently” (Site 2) | |
Environmental context and resources | Using charts to track progress and communicate goal actions (.a) |
“we will have their goals up on the wall and we will tick them off and its, it’s exciting for nurses and patients to see…. or well anyone who helps that patient… to see that it’s been ticked off, is a big achievement on everyone's behalf” however staff identified this was a “more reactive than proactive” approach (Site 1) |
Interdisciplinary teamworking
Shared decision-making
“So, if we’re grappling with it and we’re expecting them to have some kind of concept, it’s really hard …to do it so early” (Site 3).“So actually, is the goal-setting with them futile or not effective, because we’re doing it at the wrong time for that particular patient” (Site 1) (Beliefs about consequences, TDF).
Meaningful and specific goals
“it’s very clinician-driven in the inpatient setting…in the community setting, … they’re back at home, it’s more empowering, because they’re back in their normal environment” (Site 4).
Action planning, feedback and review
Phase 2- adapt the knowledge to context, select, tailor and implement interventions—methods and results
Participants
Site | Disciplines represented | Gender | Average Age | Average years of experience in the profession | Average years of experience in rehabilitation |
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Site 1 (n = 10) (1 missing data points) | Dietetics, Neuropsychology, Nursing, Physiotherapy, Rehabilitation Consultant, Speech Pathology | 100% female | 33.89 (± SD 7.66) | 12 (± SD 8.63) | 7.53 (± SD 6.05) |
Site 2 (n = 12) (2 missing data points) | Neuropsychology, Nursing, Occupational Therapy, Physiotherapy, Rehabilitation Consultant, Social Work, Speech Pathology | 100% female | 39.80 (± SD 9.39) | 14.25 (± SD 7.44) | 9.00 (± SD 5.49) |
Site 3 (n = 10) (1 missing data point) | Nursing, Occupational Therapy, Physiotherapy, Rehabilitation Consultant, Speech Pathology | 20% male | 40.00 (± SD 8.40) | 15.56 (± SD 8.95) | 9.44 (± SD4.90) |
80% female | |||||
Site 4 (n = 14) (2 missing data points) | Allied Health Assistant, Dietetics, Neuropsychology, Nursing, Occupational Therapy, Physiotherapy, Speech Pathology, Social Work | 100% female | 39.82 (± SD 11.72) | 12.64 (± SD 10.50) | 7.82 (± SD 5.67) |
Site 5 (n = 5) (1 missing data point) | Dietetics, Occupational Therapy, Speech Pathology | 100% female | 41.75 (± SD 14.24) | 18.50 (± SD13.77) | 16.70 (± SD 12.77) |
Procedure
Results
Interventions | Active goal-setting ingredient addressed | TDF domains addressed | Intervention Functions | Behaviour Change Technique |
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Staff Education and Training sessions
| Interdisciplinary goal-setting Shared decision-making Specific and meaningful goal-setting Action Planning, feedback and review | Knowledge Beliefs about consequences Social Role and Identity Skills Beliefs about capabilities Social influences | Education Modelling Enablement Training | Information about health consequence Demonstration of the behaviour Instruction on how to perform the behaviour Behavioural practice/rehearsal Framing and reframing Self-monitoring of behaviour (audits) Feedback on behaviour (audits) |
Purpose: To enhance understanding of; | ||||
→ The difference between goals and actions, → How to frame long-term and short-term goals → Action plans and coping plans to achieve goals → Skills to facilitate SDM → How teams can work together to include the client → Using measurement tools and prompts | ||||
Modules:
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→ An introduction to goal-setting → Collaborative interdisciplinary goal-setting → Goal-setting and Action Planning → Motivational Interviewing → Goal-setting measures and tools → Talking Mats training online
Materials: Training manual, handouts, references and PowerPoint presentations, online resources | ||||
Keyworker model and workplace instruction
| Interdisciplinary goal-setting Shared decision-making Specific and meaningful goal-setting Action Planning, feedback and review | Skills Environmental Context Social Role and Identity | Environmental Restructure Training | Restructuring the social environment Instruction on how to perform the behaviour |
Purpose: To enhance client and family involvement in goal-setting and rehabilitation | ||||
Content: Workplace instruction providing description of role and responsibilities | ||||
Materials: Workplace instruction, orientation training | ||||
Case conference restructure
| Interdisciplinary goal-setting Specific and meaningful goal-setting Action Planning, feedback and review | Environmental Context | Environmental Restructure Enablement | Restructuring the social environment (processes) Framing and reframing Prompts and cues |
Purpose: To provide a framework for meaningful interdisciplinary goal-setting and action planning | ||||
Content: Background client information, current function, common goal focus, long term hope/dream goals, goals for the episode of care, weekly goals, client actions, staff actions and discharge planning | ||||
Materials: Electronic template to be pasted into medical records, chairing guidelines, workplace instructions defining roles and responsibilities of team members | ||||
Communication goal and action boards
| Interdisciplinary goal-setting Shared decision-making Action Planning, feedback and review | Environmental Context | Environmental Restructure | Prompts and cues Restructuring the physical environment |
Purpose: To enhance client and family involvement in goal-setting and rehabilitation, to enhance the role of the nurse to support action planning | ||||
Content: Long term goals, goals for the episode of care, weekly/short term goals, client actions and estimated discharge dates | ||||
Materials: Paper copy | ||||
Client workbook
| Shared decision-making Specific and meaningful goal-setting Action Planning, feedback and review | Knowledge Skills | Education Training | Information about health consequence Instruction on how to perform the behaviour |
Purpose: To enhance client knowledge and expectations, to provide a framework for staff to facilitate goal-setting | ||||
Content:
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→ What is rehabilitation? → Why do I need rehabilitation? (fillable) → Who may I meet in rehabilitation? → Your rehabilitation service (tailorable) → What is a goal? → How do I set a goal? (tailorable templates) | ||||
Materials: Editable PDF, provided as hard copy to clients | ||||
Client Rehabilitation flyer
| Shared decision-making Specific and meaningful goal-setting | Knowledge | Education | Information about health consequence |
Purpose: To enhance client knowledge and expectations Content:
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→ What is rehabilitation? → What is a goal? → Who may I meet in rehabilitation? (tailorable) → Available facilities (tailorable) → What to bring (tailorable) → Your rehabilitation routine (tailorable) | ||||
Materials: Editable PDF, provided as hard copy to clients |
Interventions
Site | Interventions | Who | What | How | When | Where |
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Site 1 | Case conference restructure & guidelines | MDT meeting (Client not present) | Formulation of common goals, staff actions and client actions | Face to Face group | First case conference (Client not present) Weekly thereafter | Meeting room on ward |
Client goal boards | Nominated team member and client | Discuss with the client and display goal boards in room | Prepopulated from case conference | After each case conference | Rehabilitation ward | |
Staff education and training | Site facilitator | Goal-setting education, workplace process education | PowerPoint presentations, case discussions and 1:1 sessions | Prior to and throughout implementation/on orientation to service | Meeting room | |
Two nominated staff | Talking Mats Training [41] | Online training and assignments | During implementation | Online | ||
Site 2 | Client rehabilitation flyer | Intake nurse | Educational brochure | Face to face | Prior to admission | Acute hospital wards |
Goal-setting workbook | Administration officer | Print client booklets | On ward computers | Prior to admission | Rehabilitation reception | |
Admitting nurse | Give client booklet | Face to face | On admission to rehabilitation ward | At client bedside | ||
Link worker (Key worker) and client | Goal-setting and rehabilitation education and goal negotiation | Face to face | Within 48 h of admission | Rehabilitation ward | ||
Case conference restructure & guidelines | MDT (Client not present) | Formulation of common goals, staff actions and client actions | Chaired by consultant/NUM or Advanced AHP | First case conference and weekly thereafter | Meeting room on ward | |
Client goal boards | Key worker and client | Discuss with client and display goals and actions on goal board in room | Prepopulated from case conference documentation | After each case conference | Rehabilitation ward | |
Staff education and training | Delivered by the site facilitator | Goal-setting education, process education and workplace instruction | PowerPoint presentations, case discussions and 1:1 sessions | Prior to and throughout implementation/on orientation to service | Meeting room on ward | |
Two nominated staff | Talking Mats Training | Online training and assignments | During implementation | Online | ||
Site 3 | Goal-setting workbook | Admitting nurse | Long term goal-setting discussions, and goals for the episode of care set | Documented using the goal-setting workbook | On admission to rehabilitation ward | Rehabilitation ward |
All disciplines | Complete -How do I set a goal? Templates and action plans | Documented using the goal-setting workbook | On initial assessments and updated in treatment sessions thereafter | Rehabilitation ward | ||
Staff education and training | Delivered by the site facilitator | Goal-setting and rehabilitation education and goal negotiation skills | PowerPoint presentations, case discussions and 1:1 session | Prior to and throughout implementation/on orientation to service | Meeting room | |
Two nominated staff | Talking Mats Training | Online training and assignment | During implementation | Online | ||
Site 4 | Goal-setting workbook | Intake nurse | Goal-setting discussions, long term goal-setting and goals for the episode of care discussed | Documented using the goal-setting workbook | On intake assessment | Consultation room |
All disciplines | Weekly goals and actions set, reviewed and updated | Documented using the goal-setting workbook | On initial assessments and follow up reviews | Consultation rooms or therapy areas | ||
Staff education and training | Delivered by the site facilitator | Goal-setting and rehabilitation education and goal negotiation skills | PowerPoint presentations, case discussions and 1:1 sessions | Prior to and throughout implementation/on orientation to service | Meeting room | |
Two nominated staff | Talking Mats Training | Online training and assignments | During implementation | Online | ||
Site 5 | Goal-setting workbook | Care Coordinator (Key worker) | Goal-setting discussions, and goals for the episode of care discussed | Documented using the goal-setting workbook | On initial assessment | Home visit or consultation room |
All disciplines | Weekly goals and actions set | Documented using the goal-setting workbook | On initial assessments and follow up reviews | Home visit or consultation room | ||
Staff education and training | Delivered by the site facilitator | Goal-setting and rehabilitation education and goal negotiation skills | PowerPoint presentations, case discussions and 1:1 sessions | Prior to and throughout implementation/on orientation to service | Meeting rooms | |
Two nominated staff | Talking Mats Training | Online training and assignments | During implementation | Online |