Pilot of a person-centred, interdisciplinary approach to goal setting in Ireland’s National Rehabilitation Hospital: a study protocol

Research questions, aims and objectives

Research Question 1: What is the patient experience and perspective of a shared decision making, interdisciplinary goal setting process in a rehabilitation hospital?

Research Question 2: What is the staff experience and perspective of a shared decision making, interdisciplinary goal setting process in a rehabilitation hospital?

Guided by these research questions, we intend to capture the patient experience of the new process, explore the degree of person centeredness of patients’ goals and whether the patient feels included in decisions about their care. From a staff perspective we will qualitatively explore their experience of the new process as well as how the process relates to their interprofessional values and socialisation.

Research Question 3: What are the barriers and enablers to implementing and normalising this process in a rehabilitation hospital?

Guided by this research question, we will use the data collected to identify barriers and enablers to implementation of an IDT goal setting process. These barriers and enablers can later be used to co-design behavioural interventions and further supports to facilitate hospital wide implementation of the goal setting process. This will likely be the subject of a later study by the project team.

Data will be collected by two embedded researchers. Embedded researchers have been defined as knowledgeable researchers working with a team that will be responsible for implementing changes (Churruca et al., 2019). During the piloting of a shared decision-making IDT goal setting process within Ireland’s NRH, embedded researchers (LC and ZT) will a) capture staff and patient experiences of this new process, and b) identify potential barriers and enablers to implementation within the hospital. Learning from this will not only be disseminated into the literature base, but feedback will be utilised by the quality improvement team within the hospital who are responsible for finalising and implementing a new goal setting procedure (see “Public and patient involvement”).

Study design

This study will use a mixed methods approach and is focused on the piloting of a shared decision making, interdisciplinary goal setting process with three teams in Ireland’s National Rehabilitation Hospital. By capturing staff and patient experiences using multiple and mixed methods, we can gain insight into the phenomenon of shared decision making, IDT goal setting from different perspectives as well as barriers to implementation in this context. Qualitative and quantitative data will be collected from consenting staff and patients involved in the pilot, using semi structured interviews and self-report measures. It should be noted that elements of this study design may be subject to change due to organisational constraints and factors beyond the researcher’s control. Any changes to the study design will be registered with the protocol.

Study setting

This study will take place in the National Rehabilitation Hospital (NRH), Ireland, a 120 bedded rehabilitation hospital. The NRH is a national, specialist, tertiary university hospital providing complex specialist rehabilitation services to adults and children who have an acquired illness or injury. The NRH is a part of the Ireland East Hospital Group and Ireland’s Integrated Rehabilitation pathway with close clinical links with national spinal and neurosurgical centres at acute hospitals. As Ireland’s only complex specialist rehabilitation hospital the NRH accepts patients from hospitals and health care facilities throughout the country. Consultant led interdisciplinary teams provide speciality programmes in acquired brain injury; stroke; spinal cord system of care (SCSC); prosthetic, orthotic and limb absence rehabilitation (POLAR), and paediatric family-centered rehabilitation. The Stroke, POLAR and paediatric programmes each have one in-patient unit, SCSC programme has three units, and the Brain Injury programme has four units. The hospital is transitioning from paper healthcare records to an electronic patient record system (EPR). The new goal process designed for an EPR is being introduced initially in paper format.

Eligibility criteria

The study will recruit participants among the patients and staff of the National Rehabilitation Hospital. Eligible patient participants will be the inpatients receiving rehabilitation in the NRH, admitted to one of the units enrolled in the intervention study, after the introduction of the new goal setting process. Patients will be excluded if they have severe cognitive or communication impairments resulting in the inability to participate in the interview. Staff members eligible for the study participation will be the staff members working on one of the participating units during the time of the trial.

Intervention

This study will focus on the pilot of a new goal setting process in Ireland’s National Rehabilitation Hospital. The new goal process was developed in response to feedback from and in collaboration with NRH staff and patient representatives. In the implementation of complex healthcare interventions, it is likely that a co-design approach with tailoring to specific contextual barriers and enablers will be more successful (Craig et al., 2013). The new goal process was created with this in mind, informed by iterative rounds of feedback from staff and patients. It spans the rehabilitation journey from pre-admission to the NRH inpatient rehabilitation programmes to discharge and life after the NRH. Documentation to capture goals and the interdisciplinary care plan was changed to meet the requirements of the introduction of the EPR.

The change of the goal setting process is being accomplished in an iterative manner, based on the principles of person-centredness, partnership and patient goals driving the rehabilitation activities and schedule. Prior to admission, the goal process will be introduced to the patient and/or family through contact with members of NRH staff providing both written and verbal information. Gathering the person and family’s story—in order to getting to know the person and what matters most to them—will capture the patient’s or their representative’s understanding of their health condition, hopes and visions for life after rehabilitation and their three to five identified goals for their admission, including their perception of the importance of each goal and their proximity to achieving it.

The initial goals will be discussed during a goal capturing meeting held within the first two–five days of admission. As soon as practical within the first two weeks, the goal, action and care planning meeting will take place, where the patient and/or family will meet with key members of the interdisciplinary team (medical, nursing; HCA and relevant HSCP staff) to formally document the patient’s long-term goals in the EPR. The team then collaborates with patient on identifying the short-term goals that underpin each longer-term goal identified. The new documentation captures the patients’ identified goals; the short-term goals underpinning the main goals; tasks and actions to be completed by both IDT members and the patient and factors that will support or interfere with achievement. Establishing peer patient group sessions to discuss long and short-term goals will be introduced and will take place on a regular basis.

Reviewing and revisiting goals will be a continuous process that is both formal and informal and includes the person and/or their family. New short-term goals can be added at any time and the patient may also revise their long-term goals during any of their goal review meetings and discussion. The interdisciplinary team review on a weekly basis may also include longer sessions with the patient and family and can be complemented by intermittent formal IDT review meetings with the patient and/or family (Figure 1).

Figure 1. The new IDT goal setting process.

Data collection

Quantitative data

Measures

For patients the self-report measures (C-Cogs and CollaboRATE) will be administered shortly after the initial goal setting meeting (see intervention description). These measures are designed for use after a specific consultation and are therefore best used in this way. For staff participants the ISVS-9B will be administered at three time points (prior to the trial, after new goal setting process has begun, and at the conclusion of the trial) and the NoMAD administered alongside it at time three. See Table 1 below for data collection time points.

Patient measures

C-Cogs

The Client-Centredness of Goal Setting (C-COGS) (Doig et al., 2015) is a 13 item instrument designed to measure the degree of client-centredness of goal-planning approaches from the client’s perspective. It has three subscales (Alignment, Participation and Goals) and is scored on a 5-point Likert scale (1=Strongly disagree, 5=Strongly agree). The participation sub-scale measures the person’s perceived participation in the goal setting process and can be scored separately (range 6–30). The goals sub-scale measures the ownership, importance, meaningfulness and relevance of the individual rehabilitation goals, and the average is calculated across the goals (range 4–20). A total score can be generated by adding the sub-scale scores, higher total C-COGS scores indicating higher levels of client-centredness of goal planning. The C-COGS is characterised by good internal consistence (Cronbach alpha=0.82) (Prescott et al., 2019).

CollaboRATE

The CollaboRATE (Barr et al., 2014) is a short patient-reported measure of shared decision making that patients complete following the goal planning meeting. It contains three brief questions, measuring the dimensions of the health issue, the elicitation, and the integration of patient preferences. It is rated on 5-point Likert scale (0=No effort was made, 4=Every effort was made), scores ranging from 0–12. Higher scores indicate greater efforts made to support the patient’s participation in the shared decision-making process. The CollaboRATE evidences concurrent validity with other measures of shared decision-making and excellent intra-rater reliability (Barr et al., 2014).

Staff measures

ISVS-9B

The ISVS-9B is the short version of the original 21 item Interprofessional Socialization and Valuing Scale (ISVS-21) (King et al., 2016). It is a self-report instrument, assessing individuals’ beliefs, behaviours, and attitudes and is designed to measure interprofessional socialization and readiness to function in interprofessional teams. The three subscales reflect three key concepts of interprofessional practice: roles (belief), client-centeredness (attitudinal items), and conflict/negotiation (behavioural items). The scale was developed to evaluate the effect of interprofessional education and other interventions, in a pre-post-test study design. It is rated on 7-point Likert scale (7=To a Very Great Extent, 1= Not at All) and contains the option of choosing the “N/A” (not applicable). The scores are ranging from 0–63, higher scores indicating more positive views and higher expression of interprofessional socialization behaviours. The ISVS-21 is characterised with an excellent internal consistency (Cronbach alpha=0.98).

NoMAD

The Normalization Measurement Development questionnaire (NoMAD) (Finch et al., 2018) is a 23-item instrument, measuring the normalisation of complex healthcare interventions. It is based on normalisation process theory (NPT) and was developed for evaluating the status or outcome of an implementation process and the sustainability of the intervention. The first part contains three general questions about the intervention, the second consists of 20 items reflecting the four NPT constructs (coherence, cognitive participation, collective action and reflexive monitoring). The questions in the second part have two categories of answers: Option A has five options (strongly disagree–strongly agree), while the Option B participants can choose if the statement is not relevant. While the NoMAD does not have a defined scoring guide, it is often scored on a five-point Likert scale (1=strongly disagree, 5=strongly agree) (Gillespie et al., 2018; Lamarche et al., 2022). The NoMAD is characterised with good psychometric properties, demonstrating sufficiently high levels of internal consistency along the four dimensions (Cronbach alpha=0.89).

Qualitative data

Qualitative data will be collected from participating patients at the conclusion of the pilot. Semi-structured interviews will be conducted with participants autonomy and control over the discussion reflected. A topic guide has been prepared for the interviewer, but this will be flexible to each participant, and largely consists of open-ended questions designed to encourage participants to share experiences from throughout their goal setting process within the hospital. The topic guide was prepared by the embedded researchers, presented to the co-design team and specifically reviewed by two ex-patients on the team.

Qualitative data will be generated from staff also using semi structured interviews. Reflective questions will be asked about interdisciplinary teamwork and interprofessional collaboration, person centered care and shared decision making and the goal setting process itself. These key topics will be explored with open ended questions. Questions for staff have been drafted by researchers, presented to the co-design team and specifically reviewed by staff members from different disciplines.

Data management

All collected data will be safely stored and used in accordance with the Data Protection (Amendment) Act of 2003 and General Data Protection Regulation (GDPR) 2016/679. Participants’ data will be de-identified and will be presented in in reports and publications either in aggregate form or, where necessary, using pseudonyms.

Data analysis

Quantitative data

Data from self-report measures will be imported into SPSS (IBM SPSS Version 27; an open access alternative is R, or R Studio). Descriptive statistics will be used to illuminate the means, standard deviations etc, of the patient measures – C-Cogs and its subscales as well the 3-item collaboRATE. Given the small sample of patients undergoing the trial, more comprehensive or inferential statistics are not appropriate (Maximum potential sample size of 16 patients). However, these measures can be used complementary to qualitative data to gain insight into the patient experience of the new goal setting process. Furthermore, the study offers the opportunity to pilot these measures with a view to potentially using them in a hospital wide impact study in the future.

For the staff self-report measures, inferential statistics can be used to test the following hypothesis:

H1a: Interprofessional socialisation and values scores will significantly change over the course of the trial.

A one-way repeated measures analysis of variance (or suitable non-parametric alternative) can be used to test whether scores significantly change over time. An a priori power analysis was conducted using G Power and indicates that with an alpha level of 0.05, a sample of 27 staff members would be required to achieve 80% power in detecting a medium effect size. Descriptive statistics will be calculated for the staff NoMAD data – in order to investigate the perspective of staff on normalisation and implementation of this new goal setting process across the hospital.

Qualitative Data

Theoretical Grounding

The researchers will take a constructionist perspective, with a critical orientation to the analysis of qualitative data. Based on this we have selected reflexive thematic analysis as the primary method of analysis. We recognise language as an implicit tool in socially producing meaning and understanding of experiences. In this view, participants in interviews are not merely sharing their experiences but rather reflecting upon memories and constructing meaning as topics are discussed. A critical orientation to analysis means that we understand firstly, the artificial and constructed nature of the interview but also that we aim to see beyond language. If language creates one’s subjective reality, then we aim to offer interpretations of meaning beyond those explicitly stated by the participants. In the language of reflexive thematic analysis – this means including latent codes alongside semantic ones, taking an inductive approach in conjunction to a deductive one and keeping a critical perspective rather than a more essentialist one.

Analysis Method

Based on the theoretical grounding outlined above and the research questions, the co-design team have selected reflexive thematic analysis as the most appropriate method of qualitative data analysis. The lead researcher (LC) will cycle through Braun and Clarke’s six phases in an iterative, exploratory approach (familiarisation with data, generating initial codes, generating themes, reviewing themes, defining and naming themes, reporting themes) (Braun & Clarke, 2006, Braun & Clarke, 2021; Terry et al., 2017). Following transcription, the researcher will read and re-read transcripts while listening to audio recording, thus immersing herself in the data. The lead researcher (LC) will import the data to NVivo and will begin initial coding. A predominantly inductive approach will be taken with open coding on both patient and staff interview data. Codes will include semantic codes which summarise a data segment and latent codes which interrogate a deeper, underlying meaning behind a data segment. This will be based on the interpretation of the researcher. With the generation of a set of initial codes, similar meaning units will be clustered to create themes and sub-themes. From here we aim to use this analysis to construct an understanding of the patient and staff experience of the trial. For staff, this will include attitudes and expectations prior to the trial as well as reflections after the trial through using two interviews. For patients, the goal setting journey is elicited through reflections during one interview at the conclusion of the trial.

Ethics

Ethical approval for this study has been granted by the NRH Research Ethics Committee (date of approval 24/05/2022) and the UCD Office of Research Ethics (Research Ethics Exemption Reference Number LS-E-22-06-Carroll, date of approval 13/01/22).

Public and Patient Involvement

This study was co-designed by embedded academic researchers and knowledge stakeholders. The co-design team includes two former patients, members of the NRH’s IDT Quality Care Team who are responsible for organizing the implementation of new goal setting processes, and three academic researchers. This study was rapidly co-designed over a two-month period. The co-design team met weekly and collaboratively decided on appropriate research questions, measures and methods outlined in this document.

The involvement of clinicians and former patients goes beyond stakeholder consultation, as the co-researchers are contributing not only clinical expertise and knowledge alone butactively co-designed the research study collaboratively making decisions on measure selection, interview questions etc.. There is evidence that involving patients not only brings lived-experience perspective into research but increases its quality and the relevance (Brett et al., 2014; Nierse et al., 2012). Co-designing with healthcare professionals has been identified as a key factor in successful implementation of healthcare interventions and uptake of research findings (Jessup et al., 2018). The co-design team will continue to be involved throughout the research process and thus encourage organisational uptake of research findings.

Dissemination of results

A bespoke dissemination plan will be developed. We will share the iterative process during the active phase of data gathering with the internal academic and clinical community. Upon completion we will share findings in public venues (library, hospital and university space), round table discussions (academic and clinical venues), and academic presentations and workshops both within and outside of the hospital community. The end users and stakeholders are the patient and carers, academic, clinical, and managerial staff who can take findings and initiate action to address the issues identified in the project. Academic and clinical educators can also utilize the project presentation to educate clinicians, students and goal setting. Results of this study will also be disseminated through publication in in peer-reviewed academic journals and on social media. Findings will be also presented at national and international conferences and to relevant stakeholder groups.