Dr Alexandra Ziemann, a King’s Improvement Science postdoctoral research fellow at King’s College London and NIHR CLAHRC South London, reviews the discussion in a recent #impscichat Tweetchat.
The importance of involving stakeholders in implementation and improvement with the aim to improve the translation of research into healthcare practice has been increasingly recognised over recent years. The formation of the NIHR Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) in England are a prominent example: their aim is to implement research through closer interactions between academia and health services (Rycroft-Malone et al. 2013).
NIHR CLAHRC South London (@CLAHRC_SL) aimed to explore a number of key questions around stakeholder engagement in implementation science in an #impsci tweet chat on 24 May 2018. You can read a summary of the discussion in this Twitter Moment. The chat posed four questions and I have summarised the discussions below.
Q1. Should implementation scientists make more room for consultation, collaboration and co-creation with stakeholders?
First, a counter question by Liz Hoffman (Journal Development Manager at BioMedCentral, @LizHoffmanbmc): “Who are you counting as stakeholders?”. “Everyone with a stake in the implementation, eg, patients and service users, families and carers, frontline staff, managers (middle/senior), funders/payers – others?” answered Nick Sevdalis (Director of the Centre for Implementation Science, NIHR CLAHRC South London, @NickSevdalis), referring also to an article by Norris et al. 2017 on how different stakeholders define engagement.
The discussion moved on to the value of stakeholder engagement. Azza Warraitch (@Azza_Warraitch) summarised: “Implementation science needs more co-creation with stakeholders for improving the integration of evidence-based practices in policy”. And the European Implementation Collaborative (@implementEIC) highlighted that there is a “greater chance of someone ‘owning’ implementation problems and this getting them out of the way.” Nick Sevdalis provided an interesting example of the impact of patient involvement, quoting Armstrong et al. 2018 who conclude that “patient and public involvement should be considered an essential element of trustworthy guideline development”.
Participants also discussed how, where and when to engage stakeholders. Nick Sevdalis provided feedback from service users involved in research who suggested: “Don’t try to get it perfect, just try to do it.” Supporting this, King’s Improvement Science has put together resources and tools on patient and public involvement in improvement projects, and stakeholder and patient and public involvement in implementation research.
Q2: Would finding more active roles for stakeholders in implementation science lead to greater use of research evidence informing improvements in policy and services?
Annette Boaz (professor in health care research, St George’s, University of London, @AnnetteBoaz) commented on the type of evidence we have. She said: “I think we have a large body of qualitative and case studies, but it’s tough stuff to evidence quantitively. Is the evidence we have enough?” Diana Rose (professor of user-led research, King’s College London, @DianaRose160) replied: “My hunch is that it’s not a linear matter – it’s messy and so qualitative and case study methods are appropriate and not inferior to multiple regression, because life is not structured like a regression equation.”
Metz and Boaz called for a move away from collaboration and consultation processes towards co-creation in their blog post: “Where are the stakeholders in implementation science?”. Also Ocloo and Matthews postulated more active involvement in their review: ‘From tokenism to empowerment: progressing patient and public involvement in healthcare improvement’. They conclude: ‘Current models of PPI are too narrow and few organisations mention empowerment or address equality and diversity in their involvement strategies.’
Greg Aarons (Professor at the Department of Psychiatry, University of California, @Greg_Aarons) asked how to value the active contribution of stakeholders. Participants said that payment is one important way, but resources must be available, and this can often be a problem, especially for involving stakeholders at the early stages of a research project before funding is in place. Dr Jane Cloke (Programme Manager at the University of Liverpool and CLAHRC North West Coast, @ClokeJane) proposed also actively engaging stakeholders in the dissemination of research results. In this regard, Liz Hoffman mentioned the journal Research Involvement and Engagement, which is co-produced by academics, policymakers, and service users.
Q3: What are your experiences of engaging stakeholders and what do you consider the barriers/facilitators to be?
Beatriz Goulao (statistician and PhD student, Health Services Research Unit, University of Aberdeen, @beagoulao) summarised some major barriers: “lack of funding, under-confidence in how to do it, lack of time or feeling that it’s outside the scope of our research jobs”. Tricco and colleagues identified user expertise as a main enabler and lack of time or opportunity as a major barrier in their review of engaging different stakeholders in research.
Beatriz Goulao also raised the issue of stakeholder interest as a barrier and suggested more dialogue among different parties on goals and benefits to help create stakeholder engagement. Following up on that, Nick Sevdalis shared an interesting article by Ponsford and colleagues on the failure to generate interest among health professionals about an intervention that was aimed at them.
Q4. Are implementation science and co-creation of research evidence compatible?
Meerat Kaur (PhD student in quality improvement, Imperial College London and NIHR CLAHRC North West London, @kaumee) pointed towards the tensions between researchers and stakeholders in co-creation. Azza Warraitch added that co-creation is likely to be tension-ridden when stakeholders are only involved in a superficial way and suggested that the objectives of both researchers and stakeholders should be valued as equally important.
Following up on that, Annette Boaz said: “For me the hardest question is the extent to which we as researchers are willing to share our power with other stakeholders, especially service users and carers.” Katie Chadd (research support officer, Royal College of Speech and Language Therapists, @Katie_Chadd) saw a risk when researchers and funders have a set idea of their project: “No one wants key stakeholders to disagree with the principles of their research”. Beatriz Goulao regards the trend towards co-creation as inevitable: “Our power as researchers is only as big as the support we get from other stakeholders – is there applied research without users?”. Metz and Boaz concluded in their blog post that: “..challenging the power dynamics may well be an opportunity to build and sustain the use of relevant, contextualised evidence with greater impacts”.
The topic of stakeholder engagement in implementation science will also be discussed at the NIHR CLAHRC South London Implementation Science Masterclass on 17 and 18 July 2018 (#impscim18). And at the UK’s first implementation science conference on 19 July 2018 dedicated to ‘Strengthening partnerships between researchers, health professionals and policy makers’.
Armstrong MJ, Mullins CD, Gronseth GS, Gagliardi AR. Impact of patient involvement on clinical practice guideline development: a parallel group study. Implementation Science. 2018 Dec;13(1):55
Norris JM, White DE, Nowell L, Mrklas K, Stelfox HT. How do stakeholders from multiple hierarchical levels of a large provincial health system define engagement? A qualitative study. Implementation Science. 2017 Dec;12(1):98.
Ocloo J, Matthews R. From tokenism to empowerment: progressing patient and public involvement in healthcare improvement. BMJ Qual Saf 2016;25:626-632.
Ponsford R, Ford J, Korjonen H, Hughes E, Keswani A, Pliakas T, Egan M. Competing for space in an already crowded market: a mixed methods study of why an online community of practice (CoP) for alcohol harm reduction failed to generate interest amongst the group of public health professionals at which it was aimed. Implementation Science. 2017 Dec;12(1):91.
Rycroft-Malone J, Wilkinson J, Burton CR, Harvey G, McCormack B, Graham I, Staniszewska S. Collaborative action around implementation in Collaborations for Leadership in Applied Health Research and Care: towards a programme theory. Journal of health services research & policy. 2013 Oct;18(3_suppl):13-26.
Tricco AC, Zarin W, Rios P, Nincic V, Khan PA, Ghassemi M, Diaz S, Straus SE, Langlois EV. Engaging policy-makers, heath system managers, and policy analysts in the knowledge synthesis process: a scoping review. Implementation Science. 2018 Dec;13(1):31.