How do stakeholders from multiple hierarchical levels of a large provincial health system define engagement? A qualitative study

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Abstract

Background

Engaging stakeholders from varied organizational levels is essential to successful healthcare quality improvement. However, engagement has been hard to achieve and to measure across diverse stakeholders. Further, current implementation science models provide little clarity about what engagement means, despite its importance.

The aim of this study was to understand how stakeholders of healthcare improvement initiatives defined engagement.

Methods

Participants ( n = 86) in this qualitative thematic study were purposively sampled for individual interviews. Participants included leaders, core members, frontline clinicians, support personnel, and other stakeholders of Strategic Clinical Networks in Alberta Health Services, a Canadian provincial health system with over 108,000 employees. We used an iterative thematic approach to analyze participants’ responses to the question, “How do you define engagement?”

Results

Regardless of their organizational role, participants defined engagement through three interrelated themes. First, engagement was active participation from willing and committed stakeholders, with levels that ranged from information sharing to full decision-making. Second, engagement centered on a shared decision-making process about meaningful change for everyone “around the table,” those who are most impacted. Third, engagement was two-way interactions that began early in the change process, where exchanges were respectful and all stakeholders felt heard and understood.

Conclusions

This study highlights the commonalities of how stakeholders in a large healthcare system defined engagement—a shared understanding and terminology—to guide and improve stakeholder engagement. Overall, engagement was an active and committed decision-making about a meaningful problem through respectful interactions and dialog where everyone’s voice is considered. Our results may be used in conjunction with current implementation models to provide clarity about what engagement means and how to engage various stakeholders.

Related collections

Most cited references 82

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Using thematic analysis in psychology

Virginia Braun, Victoria Clarke (2016)

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Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

Laura Damschroder, David Aron, Rosalind E Keith … (2009)

Background Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. Methods We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. Results The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. Conclusion The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.

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The behaviour change wheel: A new method for characterising and designing behaviour change interventions

Susan Michie, Maartje M. van Stralen, Robert H. West (2012)

Background Improving the design and implementation of evidence-based practice depends on successful behaviour change interventions. This requires an appropriate method for characterising interventions and linking them to an analysis of the targeted behaviour. There exists a plethora of frameworks of behaviour change interventions, but it is not clear how well they serve this purpose. This paper evaluates these frameworks, and develops and evaluates a new framework aimed at overcoming their limitations. Methods A systematic search of electronic databases and consultation with behaviour change experts were used to identify frameworks of behaviour change interventions. These were evaluated according to three criteria: comprehensiveness, coherence, and a clear link to an overarching model of behaviour. A new framework was developed to meet these criteria. The reliability with which it could be applied was examined in two domains of behaviour change: tobacco control and obesity. Results Nineteen frameworks were identified covering nine intervention functions and seven policy categories that could enable those interventions. None of the frameworks reviewed covered the full range of intervention functions or policies, and only a minority met the criteria of coherence or linkage to a model of behaviour. At the centre of a proposed new framework is a 'behaviour system' involving three essential conditions: capability, opportunity, and motivation (what we term the 'COM-B system'). This forms the hub of a 'behaviour change wheel' (BCW) around which are positioned the nine intervention functions aimed at addressing deficits in one or more of these conditions; around this are placed seven categories of policy that could enable those interventions to occur. The BCW was used reliably to characterise interventions within the English Department of Health's 2010 tobacco control strategy and the National Institute of Health and Clinical Excellence's guidance on reducing obesity. Conclusions Interventions and policies to change behaviour can be usefully characterised by means of a BCW comprising: a 'behaviour system' at the hub, encircled by intervention functions and then by policy categories. Research is needed to establish how far the BCW can lead to more efficient design of effective interventions.

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Author and article information

Contributors

Jill M. Norris: jmnorris@ucalgary.ca

Deborah E. White: dwhit@ucalgary.ca

Lorelli Nowell: lnowell@ucalgary.ca

Kelly Mrklas: kelly.mrklas@albertahealthservices.ca

Henry T. Stelfox: tstelfox@ucalgary.ca

Journal

Journal ID (nlm-ta): Implement Sci

Journal ID (iso-abbrev): Implement Sci

Title: Implementation Science : IS

Publisher: BioMed Central (London )

ISSN (Electronic): 1748-5908

Publication date (Electronic): 1 August 2017

Publication date PMC-release: 1 August 2017

Publication date Collection: 2017

Volume: 12

Electronic Location Identifier: 98

Affiliations

[1 ]ISNI 0000 0004 1936 7697, GRID grid.22072.35, Faculty of Nursing, , University of Calgary, ; 2500 University Drive NW, Calgary, AB T2N 1N4 Canada

[2 ]ISNI 0000 0001 0693 8815, GRID grid.413574.0, Research Priorities, Planning and Implementation, , Alberta Health Services, ; 11th Floor, South Tower, Foothills Medical Centre, 1403–29 St. NW, Calgary, AB T2N 2T9 Canada

[3 ]ISNI 0000 0004 1936 7697, GRID grid.22072.35, Department of Community Health Sciences, Cumming School of Medicine, , University of Calgary, ; Calgary, AB Canada

[4 ]ISNI 0000 0004 1936 7697, GRID grid.22072.35, O’Brien Institute of Public Health, Cumming School of Medicine, , University of Calgary, ; Calgary, AB Canada

Article

Publisher ID: 625

DOI: 10.1186/s13012-017-0625-5

PMC ID: 5540524

PubMed ID: 28764728

SO-VID: b41a677c-aee4-48b4-9da9-b143d392ab9f

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 12 January 2017

Date accepted : 11 July 2017

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100000145, Alberta Innovates - Health Solutions;

Award ID: 201201184

Award Recipient : Deborah E. White

Funded by: Collaborative Research and Innovation Opportunities

Award ID: 20130152

Award Recipient : Deborah E. White

Custom metadata

ScienceOpen disciplines: Medicine

Keywords: engagement,clinical networks,implementation,quality improvement,innovations,health services,organizational change,involvement,participation

Data availability:

ScienceOpen disciplines: Medicine

Keywords: engagement, clinical networks, implementation, quality improvement, innovations, health services, organizational change, involvement, participation