Facilitators and barriers to patient-centred goal-setting in rehabilitation: A scoping review

Objective Identify, map, and synthesize existing reviews, to extract and analyse the most prominent barriers and facilitators to applying patient-centred goal-setting practice in rehabilitation using the Capability, Opportunity Motivation Behaviour (COM-B) model. Design Scoping review. Data source A primary search was conducted in MEDLINE, CINAHL, EMBASE, PsychInfo, and Cochrane. Citation chaining was employed. Review methods All types of review (systematic, scoping, and narrative) studies published up to June 14, 2022 that included physical and neurological rehabilitation, patient-centeredness, and goal-setting were reviewed. Studies were scrutinized for relevance, quality was not assessed. The most prominent barriers and facilitators were synthesized using thematic content analysis and mapped onto the COM-B model. Results Twenty-six review studies covering a range of conditions and settings, acute to community were included. Barrier and facilitators were identified at patient, provider, and organizational level. Barrier themes include provider's existing beliefs about goal-setting, lack of skills, and integration into clinical routines. Patient barriers related to capacity and opportunity to participate. Organizational barriers include lack of clinical guidelines, patient preparation, insufficient provider time, and high productivity expectations. Facilitators included goal-setting guidelines, training and education of providers and patients, revised clinical routines, performance monitoring, adequate time, and resources. Conclusion Healthcare providers should be the primary target of intervention. A provider's motivation to change current practice is the most prominent barrier, followed closely by capacity and opportunity. Patients require information, training, and structured engagement opportunities. Organizations play a key role in creating the optimal environmental conditions to enable patient-centred goal-setting.


Introduction
Collaborative goal-setting is a fundamental aspect of patient-centred rehabilitation, but healthcare providers (herein referred to as HCPs) have been slow to adopt it in practice. [1][2][3][4][5][6][7][8][9][10][11] Providers are often motivated to lead goal-setting to achieve expected professional and/or organizational outcomes. [1][2][3][4] In contrast, patient-centred goal-setting involves clients in a process of goal identification and agreement, respecting client values and preferences, and resulting in personally meaningful outcomes that are measured and reported. 6 Patient-centred goal-setting helps providers and patients focus their behaviour on meaningful outcomes that improve the patient's quality of life. [1][2][3][4]7 Evidence shows engaging patients in goal-setting improves their confidence, motivation, and satisfaction with rehabilitation. [1][2][3][4]7 Providers benefit from the enhanced patient participation and improved team functioning resulting from a collaborative approach to goal-setting, which contributes to improved client outcomes. [1][2][3][4]6,7 This evidence is based on two systematic reviews about the effectiveness of patient-centred goal-setting in adult stroke rehabilitation. 1,2 In a Cochrane review, 4 the authors found that there is reasonable support for the effectiveness of a structured approach to goal-setting and its benefits, but the results were inconclusive due to the low methodological quality and study heterogeneity. 1,2,7 Also, the disparate language and terminology in these reviews makes it difficult to conclusively assess which barriers and facilitators are most frequently identified, and the knowledge gaps that need to be further studied. 7 There are several international systematic reviews, particularly in neurological rehabilitation, about barriers to patient-centred goal-setting, which limit the adoption of this practice despite the need to do so. [1][2][3][4][5][6][9][10][11] These barriers to patient-centred goal-setting include patient preparedness [1][2][3][4]6,7,11,12 ; differences between provider and patient perspectives [1][2][3][4][8][9][10][11][12][13][14][15] ; provider skills 1,3,4,6,7,9,10,12,13,[15][16][17] ; and various organizational barriers, such as time, workload pressures, and lack of approved goal-setting frameworks. [1][2][3][4]6,7,10,15 Thus, the evidence indicates the uptake and use of patient-centred goal-setting in routine practice is challenging despite its benefits. Therefore, the known barriers and facilitators need to be studied using a theoretical behaviour change model, but no such summation has been found in the literature. This omission makes it difficult to understand which behaviours need to be targeted by behaviour change interventions to enable goal-setting, and at which level (patient, provider, organizational). A scoping review allows for the identification of the number of pertinent reviews in the literature for inclusion in the analysis. 18,19 The Capability, Opportunity, Motivation Behaviour Model is a comprehensive, systematic, and commonly used framework for understanding goal-setting behaviours and identifying which behaviours to target for intervention design. 20 The objective of this scoping review is to map and describe the existing evidence about the barriers and facilitators to patient-centred goal-setting in rehabilitation as aligned with the Capability, Opportunity, Motivation Behaviour Model, for the purpose of informing targeted behaviour change interventions.

Methods
Standard scoping review methods 18,19 were modified to only include review studies due to the breadth of reviews available about patient-centred goal-setting. This approach decreases duplication and allows for synthesis of existing information. The methodological quality of the review studies was not evaluated. 19 Reporting was completed in accordance with the PRISMA extension for scoping reviews 21 (Supplementary File 1). The review protocol was not registered.
The primary research question is: What are the facilitators and barriers to applying patient-centred goal-setting in rehabilitation at the patient, provider, and organizational level?
Two authors (LC and SK) searched MEDLINE, CINAHL, EMBASE, PsycInfo and the Cochrane Database of Systematic Reviews databases from inception to 14 June 2022. In addition, reference lists of relevant articles were hand searched and screened to identify additional articles. Grey literature was excluded.
The initial search strategy was developed for MEDLINE and consisted of using the keywords Goals OR Participation OR Keyterms (Goal setting OR plans OR negotiat* OR discuss* OR propos* OR prescribe* OR develop* OR formulate* OR establish* OR identif* OR plan* OR coping plan* OR shared decision mak*) AND [Mesh Headings] (Stroke rehabilitation OR Rehabilitation / organization & administration OR keyterms [kf,tw] rehabilitation). Filter applied for systematic reviews, reviews, qualitative studies as publication types. Additional keywords were derived from relevant titles and abstracts. The search strategy was refined through multiple preliminary iterations with the assistance of the Holland Bloorview Kids Rehabilitation Hospital librarian. The MEDLINE search strategy was adapted to search the remaining databases. The search strategy for each database is shown in Supplementary File 2. All searches were conducted by the first author.
All articles were screened by four reviewers (LC, SM, HC, and SZ) and additional reviews were identified through citation chaining. The authors discussed conflicts to achieve consensus on article inclusion.

Study inclusion criteria:
• Any peer-reviewed published review study • Review studies containing barriers and facilitators to patient-centred goal-setting in rehabilitation using any type of goal-setting intervention • All client ages, with any physical and/or neurological disability who access rehabilitation • Any health professionals delivering rehabilitation • All rehabilitation settings (e.g., acute, outpatient, community, school) • Only publications written in English as translation facilities were unavailable.
Studies conducted in mental health and addictions rehabilitation were excluded because the goals and interventions are significantly different from physical and neurological rehabilitation. Standard data was extracted by one reviewer from each study: author, year, country of first author, review type, participants, type and number of primary studies, study type and aim(s), setting, and barriers and facilitators to goal-setting. 18,19 Structured content analysis was used to identify the barriers and facilitators by level (patient, provider, and organization) in each paper a second reviewer checked the data.
Utilizing the results of the content analysis, two reviewers independently grouped the codes and organized them into meaningful sub-categories using the Capability, Opportunity, Motivation Behaviour Model (Table 1). 20 These sub-categories were then collapsed into major categories and aligned to the patient, provider, and organizational level. The Capability, Opportunity, Motivation Behaviour Model sub-components are not clearly defined so the Theoretical Domains Framework was used to clarify and more comprehensively define the Capability, Opportunity, Motivation Behaviour Model sub-components for the purpose of coding, organizing, and developing major facilitator and barrier categories. 22 Any discrepancies or themes not easily coded in the content analysis underwent constant comparative analysis until there was interrater agreement. A frequency count was conducted to identify the most commonly reported barriers and facilitators.

Results
In the initial search we identified 1691 articles, which resulted in 44 included studies. After fulltext review 26 papers are included in the review. The details of the search results are in a PRISMA diagram in Supplementary File 3.
The structured content analysis of the facilitators and barriers extracted from the 26 papers resulted in 191 codes, from which 27 inductive categories were composed, 10 at the patient level, 11 at the provider level, and 6 at the organizational level. There were a significantly higher number of barriers than facilitators 23 to delivering patient-centred goal-setting identified. These results are presented in detail below.

Motivation -Automatic
The impact of patients' culture and diversity regarding goal-setting is not studied or understood. 2
We identified a few knowledge gaps in the research including, identification of optimal team structures for effective goal-setting; the impact and role of caregivers (paid and unpaid); and understanding the impact of patient-centred goal-setting with culturally diverse clients.
In this scoping review we used a multi-level, theoretically informed approach to synthesize the evidence about barriers and facilitators to patientcentred goal-setting in rehabilitation. This review is the first step toward developing theory-based and evidence-based interventions to improve the application of patient-centred goal-setting in clinical rehabilitation. We identified that providers should be the priority group for intervention and, their attitudes and beliefs about goal-setting coupled with practice competency were the most prominent barriers to practice. Patient barriers are modifiable through provider support, enabling capability-building and creation of clinical opportunities for goal-setting participation. Further, leaders and organizations are key in creating optimal clinical goal-setting environments.
Clinical messages • Clinicians have positive beliefs about patient-centred goal-setting but find it difficult to implement in daily practice. • Organizations create the implementation environment to address clinician barriers, such as ongoing coaching to improve competence, changes to clinical routines to integrate the practice and, individual and team performance management and rewards. • Patients need supports to learn what goals are and how to express them prior to clinical encounters.

Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article ORCID iD L. Crawford https://orcid.org/0000-0003-4095-1647

Supplemental material
Supplemental material for this article is available online.