Stakeholder engagement from problem analysis to implementation strategies for a patient‐reported experience measure in disability care: A qualitative study on the process and experiences

Abstract Background In implementation science, vast gaps exist between theoretical and practical knowledge. These gaps prevail in the process of getting from problem analysis to selecting implementation strategies while engaging stakeholders including care users. Objective To describe a process of how to get from problem analysis to strategy selection, how to engage stakeholders, and to provide insights into stakeholders’ experiences. Design A qualitative descriptive design. Setting and participants The setting was a care organization providing long‐term care to people with acquired brain injuries who are communication vulnerable. Fourteen stakeholders (care users, professionals and researchers) participated. Data were collected by a document review, five interviews and one focus group. Inductive content analysis and deductive framework analysis were applied. Intervention Stakeholder engagement. Main outcome measures A three‐step process model and stakeholders experiences. Results and conclusion We formulated a three‐step process: (a) reaching consensus and prioritizing barriers; (b) categorizing the prioritized barriers and idealization; and (c) composing strategies. Two subthemes continuously played a role in how stakeholders were engaged during the process: communication supportive strategies and continuous contact. The experiences of stakeholder participation resulted in the following themes: stakeholders and their roles, use of co‐creation methods and communication supportive strategies, building relationships, stimulus of stakeholders to engage, sharing power, empowerment of stakeholders, feeling a shared responsibility and learning from one another. We conclude that the inclusion of communication‐vulnerable care users is possible if meetings are prepared, communication‐friendly presentations and reports are used, and relationship building is prioritized.


| INTRODUC TI ON
Health-care research results are often sparsely translated into practice.
Implementation science is increasing in popularity, yet there is often still a considerable gap between research and practice. 1 Implementation models start with a problem analysis to identify current implementation processes, barriers and facilitators for the intervention uptake. 2,3 Then, identified barriers are prioritized, and suitable implementation strategies are selected. 2 Within the whole process, those who have a stake in the intended intervention should be involved. Stakeholder engagement is defined as 'interactions between researchers and knowledge users that may vary in intensity, complexity, and level of engagement depending on the nature of the research, the findings, as well as the needs of the particular knowledge user'. 4 Stakeholder engagement is indispensable and highly encouraged in implementation processes. [5][6][7] It is thought to improve the quality of the implementation because it adds knowledge on clinical applications, behaviours of care users and professionals, and organizations' mechanisms. [8][9][10] The study presented here is part of a research project aiming to improve the implementation of a narrative Patient-Reported Experience Measure (PREM) in disability care while engaging relevant stakeholders.
PREMs are defined as 'a measure of patients' (also read: clients and care users) perceptions of their personal experiences of the healthcare they have received'. 11 The PREM used in this research project is 'Dit vind ik ervan!' (English: 'How I feel about it'), which uses a dialogue between a care professional and a care user to measure the care users' experiences with the quality of care. 12 In the first project phase, the current state of the art of the implementation of this PREM was explored, using the Consolidated Framework for Implementation Research. 13,14 Identified barriers were the following: a top-down decision to implement the PREM, challenges performing the PREM tailored to (communication vulnerable) care user's needs, lack of preparation by both care users and care professionals, and care users not feeling safe to share their stories. 14 Therefore, in this study we focus on prioritizing these barriers and selecting strategies, which aim to improve the PREM implementation while engaging all relevant stakeholders. Relevant stakeholders are care users, care professionals, managers and quality advisors.
Engaging care users with acquired brain injury (ABI) as stakeholders is extremely challenging: they are communication vulnerable as a long-term impact of their ABI. Disabilities from ABI's are often aphasia and memory loss, psychological and behavioural problems, and physical problems such as epilepsy and fatigue. 15 These aforementioned challenges complicate care users' participation as stakeholders because this requires them to understand and comprehend complex information and react instantly in meetings where multiple stakeholders participate. 15 Besides this challenge, we encountered a twofold problem while conducting the study. First, the process of getting from problem analysis to selecting implementation strategies is not frequently reported in the scientific literature. 16 Several studies using stakeholder engagement and implementation science in disability care have been published. [17][18][19][20][21][22] Little is known about how care users can participate in a stakeholder group in a prioritization and selecting process. Descriptions of practical methods to put this process into practice and representations of communications with vulnerable care users in stakeholder groups are very limited. 17,18,20,23 Thus, clear guidance on how to translate barriers into strategies is needed. 3 The process of getting from problem analysis to implementation strategies, and how to engage stakeholders, remains a black box. 3,24 Second, little is written about stakeholders' experiences with engagement in implementation processes. 25 Consequently, little is known about stakeholders' motivations, their needs and preferences for engagement, and their subjective evaluation of their impact. 9 Having greater insight into stakeholders' experiences might provide more guidance for applying stakeholder engagement in implementation processes.
Therefore, this study aims to describe a systematic and detailed process of how to get from problem analysis to selecting strategies, how stakeholders can be engaged in this group process, and offers insights into stakeholders' experiences. The study is relevant because it might support future implementers in applying the implementation process while engaging stakeholders in a valuable manner.
To reach this aim, we answer the following research questions: • How to get from problem analysis to selecting implementation strategies for a PREM in disability care by engaging all relevant stakeholders?
• How do stakeholders experience their engagement in the process from problem analysis to selecting implementation strategies?

| Design
We used a descriptive qualitative study design. This design has the potential to describe a poorly understood phenomenon from the perspective of participants and to answer questions about process factors, for example who, what and where. 26

| Context
The study occurred at a Dutch disability care organization, "Stichting | 55 van ROOIJEn Et al.

| Participants
We composed a project group aiming to improve the implementation of 'Dit vind ik ervan!' at SGL. Stakeholders in the project group included care user representatives (n = 3), professionals working at SGL (n = 5) and researchers (n = 6). We specifically sampled stakeholders that (a) were able to communicate (with or without the use of communication supportive tools), (b) were able to be a care user with ABI or have experiences with people with ABI, and (c) be willing to work on the implementation of the PREM in collaboration with others. Exclusion criteria were being illiterate or physically unable to attend meetings. We recruited care user representatives by disseminating a communicationfriendly vacancy profile across the care user advisory board of SGL and the university network. Even though three care representatives participated initially, only one representative was able to engage in the whole process due to health issues. We recruited professionals using SGL contacts: two care professionals/PREM trainers, a team leader, a general quality manager and a quality of care policy advisor. The engaged researchers were all part of the research team: a professor, three senior researchers and a junior researcher. (see Table 1).

| Data collection and procedure
Data were collected between September 2018 and June 2019 via documents (n = 35), individual semi-structured interviews (n = 5) and one focus group.

| Documents
Between August 2018 and February 2019, six project group meetings took place. We collected 35 documents to identify details on which steps were taken and why these were taken, and to describe how stakeholder engagement was applied. Documents included notes of meetings to prepare project group meetings (n = 16), notes of the project group meetings (n = 6) and notes of reflection meetings after project group meetings (n = 13).

| Interviews and focus group
Between April and June 2019, one researcher (MvR) conducted semistructured interviews (n = 5) with one care user representative, both TA B L E 1 Characteristics of stakeholders in the project group care professionals/PREM trainers, the quality manager and the quality of care policy advisor of the project group, exploring stakeholders' experiences with being engaged in the process. We conducted semi-structured interviews because of their flexibility to improvise in-depth questions based on participants' answers. 27 For the interviews, the participants must have attended at least three project group meetings. All engaged researchers participated in a focus group, which was moderated by a researcher not involved in this study. One interview guide was developed and used for the interviews and the focus group (see Table 2). The interview guide was based on elements of stakeholder engagement, as suggested in a scoping review by Camden et al 5 The interviews and focus group discussion lasted between 32 and 58 minutes. Even though patterns were shown, and no new findings of the phenomenon were identified we did not reach data saturation because of the inclusion of only one care user as respondent for the interviews.

| Data analysis
To answer the first research question, we analysed notes of meetings to prepare project group meetings (n = 16), notes of project group meetings (n = 6) and notes of reflection meetings after project group meetings (n = 13). We used inductive content analysis, 28 Table 3 in results paragraph). To answer the second research question, we used deductive analysis applying the framework method using a pre-defined analytical framework based on a review by Camden et al 5 The framework method was used because it can produce structured output and provides a holistic and descriptive view of the data, thereby building on previous knowledge. 29 The framework method is an approach in which a matrix is formed by systematically analysing and reducing data by case and code. In the first stage-transcription, one an alignment session was held between the two researchers to compare the codes and refine the analytic framework. Next, the framework was discussed among the research team, and an agreement was reached on any refinements. In the fifth stage-applying the analytical framework, the analytical framework was applied by indexing subsequent transcripts and documents using the existing codes. The framework was iteratively fine-tuned until all documents and interviews were coded. In stage sixcharting data into the framework matrix, the final framework was placed in NVivo (version 12) using the quotes of relevant text fragments (the themes are shown in Table 4). In stage seven-interpreting the data, data were interpreted and are presented in the results section.

| Trustworthiness
Trustworthiness was safeguarded by transferability. 30 We provided information on the context in which the research took place, the data collection procedures and the analysis. To establish credibility, we used triangulation and member checking. In monthly researchteam meetings, researcher triangulation occurred, as the meetings provided opportunities to reflect on methodological issues, as well as on organizational matters (investigator triangulation). We used several data sources documents to reflect upon the process, and interviews to reflect upon stakeholders' experiences. Researchers identified themselves as stakeholders too, and their reflection was included using a focus group discussion, using the same topic guide as the one used during the interviews (method triangulation

| Ethics
Participants received written and verbal information. For the interviews, participants gave written informed consent. We assured participants that data would be dealt with confidentiality.
Anonymity was secured by code numbering the data. The study was reviewed and approved by the ethics committee of Zuyderland-Zuyd (METCZ2019006).

| RE SULTS
In the results section, first the research question 'How to get from problem analysis to selecting implementation strategies for a PREM in disability care by engaging all relevant stakeholders?' will be answered. The inductive analysis resulted in a three-step process model including 'how were stakeholders engaged', 'who was   Step 2: Categorizing and idealizing

| Process model steps and 'Who was engaged'-'what happened'-'where in the steps' and with 'what outcomes'
In this step, a care user representative, professionals/PREM trainers, a quality of care policy advisor and researchers participated.
In the third meeting, we used a group discussion led by one researcher using pen and paper to create a mind map, to visualize and discuss the relation of the prioritize barriers. We did this to understand the root causes of the prioritized barriers and to categorize them into four global directions of solution that could potentially tackle multiple barriers. In the fourth meeting, for all four directions of solution stakeholder groups described their ideal situation on A3 size paper. At the end of the meeting, the ideals for directions of solution were shared and discussed. We did this to create a shared vision of the intended outcomes of the implementation process. Figure 2 shows an picture with an example of an ideal situation.
Step Two subthemes were identified to continuously play a role in how stakeholders were engaged during the process: communication supportive strategies and continuous contact.

Communication supportive strategies
To facilitate the valuable engagement of all stakeholders, communication supportive strategies were used in all the meetings. For written information (eg meeting reports of presentations used during the meetings), we used language-based strategies, such as the use of short sentences (max 10 words per sentence), high frequently used words and one message per sentence. Moreover, we used visual strategies, such as bright colours, drawings, photographs, pictos and smileys. (see Figure 3).

Continuous contact
Before the start of the project, one researcher met individually with all stakeholders for a face-to-face introduction to the project. To provide extra support, this researcher met with the care user representatives before every project group meeting to prepare the meeting together. The researcher explained the content of the meeting using oral and visual information and provided room for questions.
Moreover, in case a stakeholder could not attend a meeting, the researcher contacted the stakeholder to explain what was done during the meeting to safeguard that all stakeholders stayed up to date throughout the process. Additionally, one researcher worked from the SGL headquarters one day a week to stay in touch and increase approachability.

| 'How do stakeholders experience their engagement in the process from problem analysis to selecting implementation strategies?'
The themes were the following: strategies to engage, factors influencing engagement and the impact of stakeholder engagement (see Table 4).

Stakeholders and their roles
Stakeholders experienced a shared responsibility for the success of the implementation and highly valued the inclusion of different per-

Stimulus of stakeholders to engage
All stakeholders were motivated to engage because they wished others working with the PREM would experience the same benefits of 'Dit vind ik ervan!' as they did. Additionally, they not only liked to learn about the quality improvement process but also the opportunity to share experiences of working with 'Dit vind ik ervan!'. All stakeholders expressed that they felt that they were an essential contributor to the project group, as they continued to participate throughout the process.

Sharing power
All stakeholders reported that they felt free in sharing their experiences and opinions and enjoyed contributing their perspectives.
They felt respected and that their opinion was valued.
Care professional/trainer: 'I might just be "that nurse," so who am

Empowerment of stakeholders
The care user representative experienced that she was empowered to share her experiences and perspectives and enjoyed speaking up for herself. Researchers learned to adapt their initial aims, which at times were too opportunistic (eg willing to move forward into selecting strategies, whereas stakeholders needed more time to discuss the barriers). Throughout the process, researchers experienced that the process does not just take six meetings, but intense collaboration over the full process period.

| D ISCUSS I ON
The aim of this study is to describe a systematic and detailed process of how to get from problem analysis to selecting implementation strategies, to describe how stakeholders can be engaged in that process, and to offer insights into stakeholders' experiences.
We formulated a three-step process to get from problem analysis to selecting strategies: (a) reaching consensus and prioritizing barriers; Looking at the identified three-step process and the way stakeholders were engaged, several principles of design thinking can be recognized (ie user-centred designs, human-centred approaches).
Design thinking is characterized by empathy for the user, context-tailored working, and ideation and iteration. It thereby leads to a focus on the needs and preferences of the users. It fits the concept of stakeholder engagement but also complements it by guiding the process of designing products, services and implementation strategies. 33 To guide the design process, the double diamond model is often used in design thinking. 34 The two diamonds represent one process of exploring a 'problem' more widely and deeply (divergent thinking) and then taking focused action (convergent thinking). 34 Although not used explicitly in our study, the diamond model has similarities with the three-step process we applied. Based on the exploration of the implementation barriers in the first study, we focused in this study on prioritizing (step 1) and understanding the root causes (step 2) of these barriers. We thereby defined the 'problem' in depth. We then brainstormed and selected implementation strategies to find the answers to the clearly defined problems, in co-creation with a range of different stakeholders (step 3). The next step will be to iteratively test the strategies on a small scale, which is also a key element of design thinking. 33 The stakeholders appreciated the use of co-creation methods throughout the process, for example the MoSCoW method. The MoSCoW method is a prioritizing tool, which we used to prioritize all identified barriers in the problem analyses. This was experienced as useful by stakeholders, because pre-defined barriers limited space for interpretation, which made the decisions easier. Stakeholders felt as if they had more time to rank the statements and that the method helped them focus on the meetings' tasks. Other studies found a similar dynamic, using co-creation methods in the engagement of care users, as co-creation methods could provide micro-level insights into the patient (care user)-centred services. 23,35 In our study, a great focus was also on using communication

| Strengths and limitations
A strength is that we used both inductive and deductive analyses for the two research questions. We used the inductive approach to explore the process of getting from problem analysis to select- A limitation of this study is the relatively small representation of care user representatives during the process. We initially included three care user representatives. However, care user representatives in this sector are fragile and we did not foresee that two out of three care users representatives would drop out. We did not opt for replacing the two, as initially their medical conditions seemed to be temporary. We could not find a publication that specified a number of stakeholders needed for stakeholder engagement in research. 18,19,25 Nevertheless, in the future, we would aim for including more care users at the beginning or opting for the inclusion of third parties (eg informal (spousal) caregivers, friends or family of care users), who would then use their experience to reflect from a care user perspective. 25 They bring in their experience to reflect from a care user perspective. This will strengthen the stakeholder engagement process and reinforce co-creation. 23

| Implications for practice and research
Our study has implications for future research and can guide those who aim to implement interventions in health care. We think that: • The presented three-step process and the practical description of the application of co-creation methods within this process can support implementers in applying the process of getting from problem analysis to selecting strategies while engaging stakeholders. Further research in different health-care settings may help researchers and other stakeholders discover the transferability and potential further use of the three-step process.
• Implementation science can learn from tools used in design thinking, such as the co-creation methods, as they help visualize and design implementation strategies while engaging stakeholders.
• Communication supportive tools can be used to support not only communication-vulnerable stakeholders but also other relevant stakeholders.
• Continuous contact with involved stakeholders is of high importance as this supports relationship building. This can be accomplished by preparing meetings together, reporting about meetings, but also by being visible in the organization.
• Composing an inclusive stakeholder group might be more time-consuming and sensitive to the dropout of vulnerable care users. Nevertheless, our study shows the possibilities for inclusive stakeholder engagement when taking into account the inclusion of more care users or third parties and using co-creation methods tailored to stakeholders' capacities.

| CON CLUS ION
The presented three-step process and the described co-creation methods might offer future implementers guidance for organizing the process from problem analysis outcomes to selecting implementation strategies by using valuable stakeholder engagement.
Valuable stakeholder engagement can be facilitated by using supportive communication strategies (not only for people who are communication vulnerable), being in continuous contact with all stakeholders, and taking time to include all relevant stakeholders, as well as building sustainable relationships. Applying these strategies, the stakeholders in our study experienced a shared responsibility for the implementation success and described their experience of engagement as relevant and valuable.

ACK N OWLED G EM ENTS
We would like to thank the care users, care professionals and management who participated in this study. We appreciate their valuable contributions and engagement as stakeholders during this study.

CO N FLI C T O F I NTE R E S T
None declared.

DATA AVA I L A B I L I T Y S TAT E M E N T
The datasets generated during and/or analysed during the current study are available from the corresponding author upon reasonable request.
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.