Implementing a tailored, co-designed goal-setting implementation package in rehabilitation services: a process evaluation

Abstract Purpose This study aims to evaluate the process of implementing an evidence-based goal-setting package into five rehabilitation services across the continuum of rehabilitation. Materials and methods This study used a mixed methods approach guided by Medical Research Council (MRC) recommendations for conducting process evaluations, the RE-AIM framework, and the Theoretical Domains Framework (TDF). This study will evaluate the reach, adoption, implementation, and maintenance of the goal-setting package over six months. Results Environmental context and resources, the clinician’s social and professional role and identity, social influences and clinician beliefs about goal-setting consequences and individuals’ capabilities were all identified as barriers or enablers throughout the implementation process. Community rehabilitation services faced challenges implementing paper-based resources, whilst inpatient rehabilitation sites faced challenges engaging nursing staff in the interdisciplinary approach to goal-setting. Social influences were an enabler in two sites that used the case conference format to facilitate setting common goals. Clinicians in all sites continued to express difficulties implementing shared decision-making with people who had cognitive impairments or were no longer progressing in their rehabilitation. Conclusions A team-based approach to implementing the goal-setting interventions centred around the case conference format appeared to be the most successful mode for implementing interdisciplinary person-centred goal-setting. IMPLICATIONS FOR REHABILITATION The rehabilitation case conference forum can be used to facilitate teams to set interdisciplinary common goals. Rehabilitation teams should add further consideration to how they can involve clients as a member of the rehabilitation team throughout the rehabilitation process. Embedding changes into existing process and using structured templates and tools can enhance the process of goal-setting in rehabilitation. Strong leadership, dedicated facilitation, audit and feedback can enhance team’s success in implementing elements of the goal-setting implementation package.


Introduction
National and international guidelines recommend implementing person-centred goal-setting in rehabilitation settings [1][2][3][4].Goal-setting is a complex intervention conducted regularly by large groups of diverse professionals, clients and family members [5].Best practice suggests four active ingredients of goal-setting in rehabilitation should be implemented: (i) interdisciplinary teamworking, (ii) action planning, coping planning, feedback and review, (iii) meaningful and specific goal-setting and (iv) involving the client in shared decision making throughout the goal-setting process [6].Whilst goal-setting is recommended in many national and international guidelines, evidence of the impact of goal-setting on activity and participation level rehabilitation outcomes remains limited [7].the lack of activity and participation level outcomes seen in the goal-setting literature may result from studies focussing on implementing only one of the active goal-setting ingredients [8][9][10][11].Understanding how teams can implement all active ingredients in the goal-setting process is warranted.a co-design approach was conducted across five rehabilitation sites to develop and implement a goal-setting package that included the four active goal-setting ingredients [12].Details of the goal-setting package have been published elsewhere [12].the co-design approach was chosen to give clinicians a unique perspective of their current practice and to ensure that clinicians within the service could be part of and lead the implementation of changes to goal-setting practice.the implementation package consisted of up to six interventions. it was tailored to the requirements of each service to maximise team ownership over the interventions and enhance adoption (table 1).Mixed outcomes were seen across sites; these results are currently in press [13]. in summary, on completion of the 12-week intervention period, improvements were noted in the common goal focus at two sites; all inpatient sites improved their action planning and specificity of their goal statements.however, despite these changes, many clients still voiced ongoing therapist-led goal-setting practices, and the types of goals that were set remained the same [13].the Medical Research council (MRc) recommend that process evaluations are undertaken to better understand why complex interventions are or are not successfully implemented in clinical practice [14].Understanding why sites were or were not successful at enhancing the active ingredients of goal-setting practice is a vital step in this implementation research program.
the Re-aiM framework (reach, effectiveness, adoption, implementation and maintenance) was chosen to guide this process evaluation as it is a frequently used, comprehensive framework that facilitates the description and evaluation of the process of program implementation [15].the Re-aiM framework highlights five critical elements in the evaluation process.Firstly, did the program Reach the identified target population?secondly, did the program have the intended Effect (this component has been published elsewhere [13].Finally, how was the program Adopted, Implemented and Maintained? [16].the Re-aiM framework has been used in many studies to plan and evaluate process evaluation studies [17].the theoretical Domains Framework (tDF) is a theoretical approach to understanding the determinants of the behaviour [18], which, when used alongside the Re-aiM framework, can describe the barriers and enablers to implementing the intervention.the tDF has been cited over 1300 times.the tDF has been used in studies to develop interventions to improve the management of mild traumatic brain injury in the emergency department and understand barriers to increasing the intensity of practice of inpatient rehabilitation stroke survivors [19][20][21].Understanding the challenges of implementing a goal-setting package targeted at all four active goal-setting ingredients will inform and enhance the future implementation of best practice goal-setting.
this study aimed to evaluate the process of implementing the goal-setting package at five rehabilitation sites across Queensland.specifically, the research questions for this study included:

Design
an explanatory sequential mixed methods design [22] guided by the Re-aiM framework [23] was used to evaluate the process of implementing a co-designed tailored goal-setting package in five rehabilitation services.Following the explanatory sequential design, quantitative findings from the implementation audits and attendance sheets informed the follow-up follow groups to explain the barriers and enablers to the implementation process.thus the results of this study are presented sequentially to address the study's aims above.this study was part of a more extensive program of research guided by the Knowledge to action Framework (Kta) and represented the evaluation and sustainability phases of the Kta [24].Further evaluation of the effectiveness of implementing the co-designed tailored goal-setting package has been published elsewhere and includes consumer commentary [13].a summary of the research questions, methods and data analysis plan is presented in Figure 1. this study was approved by the Prince charles hospital human Research and ethics committee (hRec/17/tPch/341/) and Griffith University human Research and ethics committee.the stROBe guidelines were used in the reporting of this study [25].

Participants
Five sites (three inpatient and two community rehabilitation services) participated in developing and implementing the goal-setting package and all aspects of the process evaluation.all sites included in this research program were government-funded rehabilitation services catering for a varied case mix of clientele (table 2).sites volunteered to participate in this research program through an expression of interest circulated via the statewide Rehabilitation clinical Network.

Site facilitators
One site facilitator was appointed at each site at the commencement of the program of research through an expression of interest.criteria used to select facilitators included: holding a stable position in the rehabilitation team, evidence of their facilitation skills (e.g., project management experience), teamworking, communication, and negotiation skills.these criteria were evaluated through curriculum vitae and a written suitability statement from each candidate.all site facilitators were senior clinicians and were allocated the equivalent of one day per week to drive the implementation and evaluation phases of the project.

External facilitator
each site facilitator was supported by an experienced external facilitator (aB) at least fortnightly.the external facilitator has experience supporting, supervising and mentoring senior rehabilitation clinicians and championing change in previous implementation projects.the external facilitator has experience in engaging stakeholders, diagnosing implementation problems and facilitating change [26].
Focus group participants a maximum of eight staff were nominated to participate in each focus group, with two focus groups offered per site to capture staff across shifts.all staff (medical, nursing, and allied health) working in the rehabilitation service were eligible to participate in the focus groups.efforts were made to ensure a broad distribution of disciplines and leading figures within the focus groups.all focus group participants provided written informed consent (table 3).

Procedure
implementation of the co-designed, tailored goal-setting interventions occurred at each site over a 12-week period.a vital element of the implementation plan was the inclusion of local facilitators to coordinate and support each team through the process.harvey et al. [27] describes facilitation as a key concept that activates implementation through interaction between the intervention, the recipients and the context [26].site facilitators collected data throughout implementation and promoted problem-solving discussions among the team members at each site.
site facilitators maintained attendance records at goal-setting education and training sessions.audits were conducted by the site facilitator fortnightly throughout the implementation period to determine the presence and use of each of the selected interventions.audits were designed to gather information on intervention fidelity, specifically if components of the site's individualised goal-setting implementation package were used with clients during the audit period.audit results were provided by the site facilitator to the clinicians at each site via feedback sessions.During feedback sessions, staff were prompted to self-reflect, identify barriers, and problem-solve solutions to promote behaviour change.site facilitators kept fortnightly research diaries and undertook problem-solving discussions with the external facilitator (aB) fortnightly throughout implementation.Following problem-solving discussions with the external facilitator, site facilitators changed the goal-setting package or implementation plans as required throughout the 12-week period.
On completion of the 12-week implementation period, focus groups were conducted by the external facilitator (aB) with staff at each site to evaluate the implementation process.the external facilitator (aB) had experience in running focus groups.Focus groups were guided by the Re-aiM framework, using prompts based on the theoretical Domains Framework (tDF) (see supplementary material table s1).Focus groups were audio recorded, transcribed verbatim and de-identified.Field notes were taken during the focus groups by the external facilitator.individual semi-structured interviews were conducted with each site facilitator 3-months later by the external facilitator (aB).these interviews focused on exploring if the interventions had been maintained.interviews followed the same focus group guide, were audio recorded, transcribed verbatim and de-identified.

Data analysis
attendance records for education sessions and audits of client records were analysed using descriptive statistics.a summary of changes made throughout the implementation period was descriptively summarised by the external facilitator (aB).Fortnightly site facilitator diaries, follow-up focus groups and site facilitator interviews were analysed by the external facilitator (aB) with NVivo software using template analysis [28]. the external facilitator (aB) deductively coded the research diaries, focus groups and interviews using dual coding procedures based on the Re-aiM framework and tDF categories.themes were discussed with the broader research team and agreed upon.the results of the audits, focus groups, site facilitator research diaries and site facilitator interviews are synthesised and presented in the results under each of the four Re-aiM categories: reach, adoption, implementation and maintenance.the evaluation of the effectiveness of this program of research is briefly summarised, but detailed results of the effectiveness of this implementation project have been published elsewhere [13].

Results
characteristics of each rehabilitation site are presented in table 2. a total of 7 focus groups were conducted (site 1 = 2, site 2 = 3, site 3 = 1, site 4 = 1, site 5 = 1).a total of 38 clinicians participated in seven focus groups across the five sites, with diversity in professional disciplines represented at all sites (see table 3). a maximum of 6 fortnightly audits were completed by inpatient sites only, and site facilitator diary entries (all sites) were submitted during the implementation period.community rehabilitation site facilitators experienced challenges undertaking audits due to the client's inconsistency with bringing resources to outpatient therapy sessions for review.Due to the paucity of audit data from community rehabilitation sites, this data was not included in this part of the analysis.Five site facilitator interviews were conducted three months after the completion of the final data collection.

Did the goal-setting implementation package reach all relevant staff at each site?
site facilitators conducted education and training for staff to improve their knowledge and skills in rehabilitation goal-setting and how to use the goal-setting package in their clinical practice.Most allied health staff attended the education sessions across each site with varying patterns of reach to nursing and medical staff across sites (see supplementary material, Figure 1).Only one site (site 4) achieved 100% reach to all three professional groups.

Were there barriers and enablers impacting the ability to reach all staff?
environmental context and resources were the most significant barrier to reaching each site's staff.two inpatient site facilitators (site 2 and 3) found it challenging to reach all nursing staff due to the volume of staff, part-time workforce and shift work."We did email the nursing staff on the floor all the other modules … but I'm not sure what the uptake was on that" (Site 2).Whilst site facilitators managed to reach most of the allied health staff across the team, facilitators still stated that staff turnover made it challenging to reach all clinicians, specifically in inpatient rehabilitation facilities.
"It was such a short time, and with rotations and stuff, people never got it into their… routine" (Site 3). the ability to reach nursing staff was enhanced when supported by the nursing educator in site 1, who saw it as part of their social and professional role.
…they [nursing education team] did a… blitz of running the online tutorials every session for about six weeks (Site 1).
Understanding social and professional roles and having shared responsibilities for implementing the goal-setting package enabled further reach to staff in the team.For example, the role of operational staff in sites 1 and 2 was initially overlooked when developing the implementation plan.site facilitators in sites 1 and 2 identified this throughout implementation and actively engaged operational staff throughout the remaining implementation period to ensure goal boards and client-held workbooks were present and available to clinicians during therapy sessions (table 4).

I [site facilitator] encouraged [operational officer] to become familiar with
all the patients' goal boards and to ensure that they move with the patient with bed moves [operational officer] recognised that this is a potential risk with bed moves and was happy to communicate (Site 1)

Effectiveness
the study aimed to improve four active ingredients of goal-setting practices in rehabilitation: a common goal focus (interdisciplinary team working), presence of action planning, feedback and review, meaningfulness and specificity of goal statements and client involvement in the goal-setting process.Mixed outcomes were seen across sites during client interviews and medical record audits, and these results have been published elsewhere [13]. in summary, on completion of the 12-week intervention period, improvements were noted in common goal focus and interdisciplinary team working in two sites; all inpatient rehabilitation services improved their action planning and specificity of their goal statements.however, despite these changes, many clients still voiced ongoing therapist-led goal-setting practices, and there were no significant changes in the type of goals set [13].

Adoption
To what extent did staff at each site adopt the selected components of the goal-setting implementation package?sites within this program of research chose to implement different aspects of the goal-setting package (table 1).except for site 1, all sites implemented the client workbook as part of their goal-setting package.Final site audits revealed a high level of adoption of client workbooks for eligible clients at site 2 (95%, n = 19) and site 3 (93%, n = 27) (see supplementary material, Figure 2). in contrast, staff in community rehabilitation settings found that many clients did not bring their workbooks to outpatient therapy appointments, and therefore these could not be audited.sites 1 and 2 chose to also implement the client goal boards.after the 12-week implementation, 73.33% (n = 9) of eligible clients had goal boards in site 1, whilst 92.31% (n = 12) clients had goal boards present in site 2 (see supplementary material, see Figure 3).
Four of the sites [1][2][3][4] delivered the five education and training modules throughout the implementation period, whilst site 5 delivered three of the training modules.Finally, the goal-based case conference format was implemented by two sites only (sites 1 and 2), and the audit found that all case conference discussions at these sites were completed using this format by the completion of the implementation period.

Were there barriers or enablers impacting staff adoption of the goal-setting implementation package?
clinicians' perspectives about their social and professional roles and identity presented as both a barrier and enabler to adopting the goal-setting implementation package.the role of education and training often fell to the site facilitator, and in only two sites (sites 1 and 2) was there evidence of shared leadership and delivery of education and training throughout the implementation.One site facilitator reflected on the value of the support from the allied health team leader to influence the adoption of the goal-setting implementation package within allied health."I think new sites would struggle to get this up off the ground without strong support from the team leader" (Site 2).however, this site still found challenges in engaging nursing staff to take on key worker roles.clinicians' beliefs about clients' capabilities impacted the adoption of the goal-setting package with specific client populations.the goal boards were only used with clients where clinicians felt it was appropriate.
…it only applied to maybe 75% of them [clients]…for the rehab patients who were able to engage in that discussion … and understood why they were here and what they were working on, it was really good (Site 3).
clinicians considered clients unlikely to benefit from using a goal board if they had a short length of stay in the rehabilitation service, were no longer progressing, or were awaiting external input to support discharge planning.
Probably the one patient group that we do have trouble with…is those clients that are … finished their intensive rehab phase and are moving to discharge planning (Site 1).some clinicians did not believe in the consequence of goal-setting for some client populations.clinicians in sites 4 and 5 identified that client workbooks were not provided to clients with severe cognitive impairments.likewise, in sites 1 and 2, clients with severe cognitive deficits were often omitted from receiving the client goal board; however, in these instances, clinicians identified that they still used the goal-based case conference template to facilitate goal-setting among the team.
We'd still put some goals in there, but… those goals wouldn't necessarily be fed back.It's more that the team would then have that traditional shared understanding and shared focus on this what we're trying to achieve with this person, but these are our goals, not their goals (Site 1).
clinicians' beliefs about the consequences of adopting the goal-setting implementation package affected the team's ability to adopt the interventions consistently.some staff demonstrated a lack of belief in the importance of the interdisciplinary approach to goal-setting in the client workbook.
The concept of linking everyone's goals together is lovely, I guess, that I personally am not convinced that it makes any difference to patient outcomes or the things that we're doing to get people out of hospital (Site 3).
One site facilitator found that the opposing beliefs of staff were a significant barrier to the consistent adoption of the client workbook."I don't think everyone bought in … I got feedback from certain members of the staff … that there were very divided opinions" (Site 3).conversely, some clinicians voiced that their 'accountability' to the team when the goal-setting and action planning occurred at a case conference enhanced their adoption of the interventions.
Another thing that we identified was accountability.… as the driver giving feedback … that made people accountable (Site 2).each site's environmental context and resources also impacted the goal-setting package's adoption.the adoption of the client workbook by clients and staff in community rehabilitation was impacted by two primary issues.Firstly, clients did not bring their workbooks to outpatient therapy appointments."They don't bring those booklets with them to following appointments" (Site 5).secondly, the limited access to the client workbook reduced the clinician's tendency to use the client workbook consistently.Whilst most clinician's felt that the client not having the workbook was the fault of the client themselves, one clinician did question the importance of the team's collective emphasis on the value of the workbook and how this may have impacted its use among the team.

I think it comes back to our work culture as well … are we saying how important this is to the clients and how this is important to us for the client to bring it in.
Are we conveying that?Are we getting that message across?(Site 5).client folders were used as a pre-existing tool to hold exercise record sheets in site 2, and it was decided to combine the client goal-setting workbook with the exercise folders.incorporating the client workbook into an existing process was an enabler to facilitate staff using the client workbook."The client-held record and the fact that we put the exercises in there with it, the patients seem to love it" (site 2).some clinicians stated that remembering to implement the new process was challenging where components of the goal-setting package were implemented as new processes.One site facilitator felt that team members did not remember to use the client workbook as it was not being embedded into standard clinical practice.

I think it was that allied health weren't using it. For them, it was just a piece of paper they [clients] were carrying around. …They had their first action plan, but it wasn't being reviewed. It became a forgotten resource (Site 3).
clinicians perceived that the goal-setting implementation package would increase their current workloads and that they often needed more time to use the resources.in several sites, some staff chose to use specific components of the client workbook as they found using the whole workbook time-consuming.

Were changes made to the goal-setting implementation package throughout the implementation period?
several changes were made to the goal-setting implementation package throughout the 12-week implementation period (table 5).Due to the high rotation of staff, several site facilitators requested recorded online versions of the training for orientation.some site facilitators created additional education and training sessions, such as mock case conferences and walk-around training sessions.changes were made to cease the case conference goal templates when clients were not progressing or awaiting other services for discharge; in these instances, a goal-based focus was not included, and the template became a checklist for discharge planning.

Were there barriers or enablers to implementing the goal-setting implementation package?
clinicians' knowledge and skills were identified as a barrier to implementing the goal-setting implementation package (table 6).During follow-up focus groups, clinicians stated they still faced challenges with stating the differences between goals and actions.Furthermore, clinicians still demonstrated that they controlled the goal-setting process to meet their predicted levels of recovery for the client.

Breaking the goal down to just be a week at a time [was challenging]
….timeframes were blowing out to a couple of weeks depending on the projection that you could predict for that patient (Site 2).
the environmental context at sites and clinician knowledge presented a barrier to the implementation of the goal-setting package. in sites implementing the goal-based case conference format, the case conference templates were displayed on a screen as the scribe documented, this meant staff were more aware of what was being documented, and conversations ensued from here discussing the differences between goals and staff actions increasing the perceived length of time in a case conference.

This new format actually allows staff to see what's being documented for case conference…but this does mean it takes more time (Site 2).
the potential extension of case conference time was identified as a risk during the development of the implementation plan, and the timing of the case conference was undertaken throughout implementation to monitor this.On average, across sites 1 and 2, a discussion of a new client at a case conference took 14 min, whilst a review client took 9 min.this was comparable to pre-implementation case conference timings (new client = 12 min, review client= 8 min).
sites 1 and 2 also faced significant challenges with saving and copying documents onto newly implemented electronic medical record systems as no suitable process to develop templates were available through this program.additionally, paper-based resources presented a double up in documentation requirements for staff as all team members were required to document the information in local paper charts or electronic medical records as well as client copies.electronic medical record-keeping systems did not have a client-friendly interface that could be printed for people.
the environmental context of an impending service restructure at one site posed challenges to clinicians' willingness to invest in change at the time of implementation."I'm not sure if you're aware we're also going through reform as well" (Site 5).Other site facilitators also expressed concern that broader health system changes in recent years were leading to "change fatigue" among the staff with "recent high turnover of staff, lots of leave relievers, recent move to a new hospital and massive restructure."(Site 2).
the challenge in engaging the role of the nursing staff and the fragility of relationships between allied health and nursing was noted in the inpatient rehabilitation sites.
You [the nurse] live with the patient…24/7.You've seen them at their best and at their worst.If you talk about OT, …toileting, whether they can wipe themselves or anything and they think they know the patient more than you.And they've never taken this patient to the toilet (Site 1) in one site, nurses felt disrespected when their written contribution to the case conference was overridden by allied health staff "It's not very nice if nurses are actually rushing, trying to find time to actually participate and end up hearing that it's been deleted.That's valuable time that's been wasted" (site 1).this impacted the team culture between allied health and nursing during the follow-up focus groups.
the skills of the site facilitator were an important enabler throughout the implementation of the goal-setting package.site facilitators in sites 1 and 2 adapted their delivery of education and training flexibly to suit the team's needs.Both site facilitators found using a 'mock' case conference as a training session useful to support clinicians in implementing the new case conference framework.site facilitators used current client examples to run through demonstrations and facilitated problem-solving about how and where certain team roles would contribute.
Furthermore, to engage staff with a more practical approach than the traditional didactic in-service model, one site facilitator found a 'walk around' training session useful to support the implementation of client goal boards in client rooms.
I think the sessions that worked well were me randomly walking around grabbing a goal board and grabbing a patient, and then sitting down and having a conversation with them about it and showing the staff that were with me that this is important to the patient (Site 1).
additionally, skilled facilitators identified personalities, relationships and skills in others that they could empower to influence the implementation."These strong feelings could be a major asset in convincing others to adapt their way of thinking" (Site 1).site facilitators received support from the external facilitator to develop their knowledge, self-reflection and facilitation skills in promoting behaviour change among their team members throughout the implementation.like the challenges found in adopting the interventions, social influences remained an enabler or barrier in the ongoing implementation.Whilst some sites felt that there was sufficient buy-in from clinicians on the floor, which assisted in the successful implementation, one staff member in another site highlighted concerns about the success of the implementation when there was not consistent support among the team.
It … needs to be consistently advocated for…I've walked past some conversations on the ward with some people who don't see the value in it, and I think it's probably worth everyone who is involved in it … making sure …to advocate … because I think there's not full buy-in at the moment from the staff (Site 3).

Maintenance
Were components of the goal-setting implementation package sustained at three months?all site facilitators were encouraged towards the end of the 12-week implementation period to consider how the goal-setting implementation package would be incorporated into a business-asusual process and how ongoing cycles of quality improvement could continue to enhance the implementation of the goal-setting package.site facilitators in sites 2, 4 and 5 nominated new site facilitator champions to continue to drive and review the implementation as they no longer held a role within that service, whilst facilitators from sites 1 and 3 continued in their current position.however, all dedicated support and funding for site facilitators ceased after the implementation period.
Facilitators at sites 1 and 2 stated the case conference process and goal boards were continuing to be used three months after the final data collection was completed."It's sticky.It stuck, they're still using it.There haven't been any major changes since we've finished the project" (Site 1).Ongoing education and training were occurring in sites 1 and 2 for staff orientating to the service.sites 3 and 4 were not consistently implementing the client workbook or staff education and training at three months."Yes, well, it's really been phased out.The uptake hasn't been good at all, I guess… the clients aren't receiving their folders.They aren't even receiving that paperwork anymore" (Site 4).site 5 reported intermittent use of the client workbook at three months follow-up but no ongoing use of the education and training modules.

Were there barriers or enablers to maintaining the use of the goal-setting implementation package components?
environmental context and resources presented the most significant barrier to maintaining the goal-setting package.site facilitators felt that the use of the goal-setting implementation package was reduced after the formal implementation period.the value of and need for ongoing facilitation was raised by all site facilitators."although we've embedded this change, I don't know that we've advanced it without the funding and support."(Site 2).
site facilitators also felt that the lack of ongoing audits and feedback to the team impacted the team's continued use of the goal-setting package."To be completely honest… after I was not there, auditing and providing feedback and being that driver, it fell apart.It didn't take long for people to forget" (Site 3).Furthermore, organisational priorities, such as the implementation of medical record systems and pressures on length of stay, continued to impact the ongoing maintenance of the goal-setting package.
When I had set that up, the integrated electronic medical record system was a couple of weeks away, and the nurses were on lockdown and weren't allowed to do any additional other training… Everything was related to the integrated electronic medical record.The nurses requested at least a couple of months to get themselves used to the integrated electronic medical record before starting this up again (Site 3).

Discussion
this study aimed to evaluate the process of implementing a co-designed, tailored goal-setting package in five rehabilitation services across the continuum.Barriers and enablers to implementing the goal-setting package have been identified and mapped to the Re-aiM framework.these barriers and enablers will aim to inform future goal-setting implementation studies.
several barriers and enablers impacted the implementation of the goal-setting package, specifically throughout the adoption and implementation processes.Firstly, clinicians' knowledge of the importance of the distinction between goals and actions was a barrier to implementation.secondly, community rehabilitation sites faced significant challenges in implementing client workbooks due to the outpatient nature of the program.support from the local site facilitators was an important enabler.Finally, whilst the templates and prompts to restructure the environment were useful, there were several challenges synchronising case conference templates and goal boards with existing information technology systems.
Despite education and training, on completion of the intervention period, some staff actions were still stated as client goals in all sites [13].some clinicians in this study did not recognise the importance of the distinction between goals and actions.the distinction between goals and action plans is essential to enhance the motivational aspects of goal-setting, ensure goals are challenging, and direct the specificity of treatment plans.Many goal statements were phrased as 'to continue to practice' a particular task or therapy activity and were not always a 'desired future state' [7]. in previous studies, clinicians have demonstrated maintaining control over the goal-setting process, often resulting in goal-setting 'describing the rehabilitation process rather than driving it' ([29] p.211).therefore, focusing on staff actions rather than client goals may reinforce a therapist-led approach to goal-setting, minimising the impact goal-setting can have on influencing one's performance and autonomy throughout rehabilitation.
the different rehabilitation service contexts (inpatient and community rehabilitation) experienced different barriers and enablers.community rehabilitation teams faced challenges implementing a practice that relied on clients bringing their personalised, paper-based resources to each appointment.One rehabilitation service in the UK had previously implemented a Goal-setting and action Planning (G-aP) workbook with good compliance; however, therapy was predominantly conducted in the client's home, negating the need for the paper-based resource to be transported [30].the lack of presence of the client workbook at community rehabilitation appointments also limited the use of audit and feedback as a behaviour change intervention.inpatient rehabilitation services in this study benefited from being co-located with the client 24/7, with much more control over using a client workbook and more accessible audit and feedback processes.audit and feedback are more effective when delivered in a 'higher dose' throughout the implementation [31].similar effects were seen in this study for inpatient sites where audits and feedback could be conducted regularly.sites 1 and 2, which chose to concentrate on implementing the interventions as a team in the case conference, showed more improvements across key elements of best practice goal-setting than those services aiming to implement the interventions, such as the client workbook in a siloed discipline approach.individual clinicians' roles and responsibilities within the team when conducting goal-setting in the case conference forum may have been key in enhancing the active goal-setting ingredients in sites 1 and 2. Furthermore, structure and effective chairing have increased staff satisfaction with case conference meetings and enhanced teamworking [32]. in this study, having a common goal focus as the expectation in case conferences helped to move teams toward a more interdisciplinary rehabilitation approach.this is important as interdisciplinary rehabilitation teams have been seen to have improved outcomes for stroke survivors when compared to multidisciplinary teams [33].
site facilitators played a prominent role in influencing staff and supporting the team members to implement the goal-setting implementation package.the dedicated facilitation role was identified as a key enabler in adopting and implementing the goal-setting package.evidence of deterioration in adoption and implementation was seen after the completion of the implementation period, where funded support for the facilitator had ceased.a previous systematic review highlighted the importance of facilitation, which identified that primary care practices were 2.76 times more likely to implement recommendations when supported by a facilitator [34].Facilitation is a high-level skill that requires development over time [26].Facilitators need a credible knowledge base of the content and specific local processes, project management and communication skills [26].Facilitators should be reflective, unbiased and respectful; they should aim to build trust and empower others through setting common ground rules, active listening and demonstrating emotional engagement [26].
On completing the 12-week pilot in this study, dedicated site facilitation support and funding ceased.three site facilitators left their rehabilitation teams and were encouraged to nominate new site facilitators to continue to champion goal-setting practices un-resourced.two of these sites discontinued the goal-setting implementation package at three months follow-up.Facilitators within sites 1,2 and 3 had remained within their teams but without dedicated facilitation support or funding.site 1 and 2 continued with interventions as intended, and site 3 planned to revise the goal-setting implementation package.Given the complex nature of behaviour change required at a team level to implement improved goal-setting practices, ongoing supported facilitation is likely needed.if this cannot be additionally resourced, strategies such as communities of practice (cOP) may be an avenue to support facilitators to continue to drive change within their service [35].a current research project plans to use a community of practice to provide ongoing support to remote clinicians to deliver ciMt [36].this is specifically relevant when considering the high staff turnover in healthcare settings.to enhance sustainability, consideration of improved or mandated orientation education and training may contribute to the ongoing sustainability of changes.
templates and prompts used in the case conference format and client workbook were useful to ensure all elements of goal-setting, action planning feedback and review were included in the goal-setting process.sites that were most successful at implementing and maintaining the goal-setting implementation package were sites that had embedded specific prompts into core or existing processes within the rehabilitation unit, specifically, the case conference forum.however, the challenge of integrating paper and electronic records was a barrier.existing electronic medical record systems do not provide a client-friendly interface to involve the client.integrating goal-setting methods into existing electronic medical record systems has also been identified as a challenge in a previous process evaluation aiming to enhance goal-setting practices [37].Future development of electronic medical record-keeping systems should reduce the need for double documentation and ensure that client and clinician interfaces can be included.
limitations in this study include a short implementation time frame due to project funding.Further data from audit processes in community rehabilitation services would have strengthened conclusions and may have promoted more behaviour change in community services.the external facilitator had previous working and professional relationships with three site facilitators (site 1,2, and 3). the external facilitator had working relationships with staff in one other service (site 4).Given the significant role of facilitation identified in this and many previous studies, further training for site facilitators to support their facilitation skill development would have been of value [26,34,38].an additional limitation of this study includes the need for formalised transition into a maintenance phase and the lack of use of sustainability frameworks.Due to pragmatic reasons following the 12-week implementation period, site facilitators were given some tools and resources to continue their work but no ongoing formal support or further accountability.this study's strengths include strong theoretical frameworks and a comprehensive approach to data collection using quantitative and qualitative data from multiple sources.

Conclusion
teamwork is vital for implementing person-centred goal-setting and may be the most important ingredient to successfully implementing the goal-setting implementation package in clinical practice.site facilitators identified the lack of dedicated facilitation beyond the end of the implementation period as a barrier to maintaining the use of the goal-setting package.templates and prompts embedded in existing processes helped ensure that components of action planning, feedback and review were incorporated into the goal-setting process.site facilitators reported that regular audits and feedback (where it could be conducted in inpatient rehabilitation) helped drive change within the rehabilitation team.Future research would benefit from exploring how teams work together and implement shared responsibilities for goal-setting and action planning and how the client can be incorporated as an equal team member to drive their rehabilitation journey.

1 .
(a) Did the goal-setting package reach all relevant rehabilitation staff at each site?(b) Were there barriers and enablers impacting the reach to all staff?2. (a) to what extent did staff at each site adopt the selected components of the goal-setting package?(b) What barriers or enablers impacted the staff's adoption of the goal-setting package? 3. (a) What changes were made to the goal-setting package implemented throughout the study?(b) Were there barriers or enablers to implementing components of the goal-setting package? 4. (a) Were the goal-setting implementation package components maintained three months following the implementation period?(b) Were there barriers or enablers to maintaining the use of components of the goal-setting package?

Table 3 .
Demographics of focus group participants.

Table 4 .
barriers and enablers to the reach and adoption of the goal-setting implementation package.
"I find that it just encourages that more team collaboration.Previously we would just work in a lot more of an individual stream basis.I guess it's just that awareness that we have the case conference, the collaborative goal-setting just starts those conversations …an opportunity for a physio to talk to, say, an OT going, "Oh, actually I got this goal from Mrs Smith and actually I think it's an area that we can both work on in therapy."I think it's just that awareness …it and having those conversations, where as previously, when we were less involved in this process, there was a tendency to really just think more discipline-specific goals" (Site 2)"we thought that we could bring the books to case conference so that we can read out what their goals are and what their action plans are, so that it's a bit more in your face.… it makes you a bit more accountable."(Site 3)

Table 5 .
Changes made to components of the goal-setting package throughout implementation.

Table 6 .
barriers and enablers to the implementation and maintenance of the goal-setting package."Ithink that's potentially where it blew out a lot of the time was because we were so caught up in the terminology … it was the nitty-gritty of the actual wording of the goal and the action" (site 2) "I'm not sure if you're aware we're also going through reform as well"(Site 5) "recent high turnover of staff, lots of leave relievers, recent move to a new hospital and massive restructure-likely some "change fatigue" amongst staff" (Site 5) "In regards to the template itself, even though I had attended the groups and how it would be used, it was actually a bit confusing to what nursing would contribute"(Site 2) "it's not very nice if nurses are actually rushing, trying to find time to actually participate and end up hearing that it's [nursing contribution to case conference] been deleted.That's valuable time that's been wasted"(Site 1) "with [site facilitator's] mentoring, every now and then just making us rethink, I think it's an easy enough process to take on board."(Site 1) "I think they needed to see it in action before they would believe that it would work.They needed to get in and do it and feel it and see it and go, "Okay, this isn't extra work.…it's not such a big change, and it is more patient-centered." I think that once they realized that they were