14.1 Introduction

Resilient healthcare embraces complexity, performance variability and acknowledgement of when things go right [1]. Going right means that the system functions as it should and people work-as-imagined; when things go wrong it is because something has malfunctioned or failed.

One factor that can contribute to the development of resilient healthcare is service user involvement and engagement of patients and service users in decision making processes at the individual and organizational level of healthcare services. User involvement can, which can impact on how knowledge is shared and situations of adversity managed.

In this chapter, we will focus on a modified stakeholder analysis [2], of resilient healthcare taking mental health care and service user involvement as a case example. To guide the analysis we will draw on aspects of the analytical framework proposed by [3] as they describe different aspects of lay participation in healthcare decision-making.

Definition and Categorization of Stakeholders. A stakeholder can be defined as “persons or groups that have, or claim that they have, ownership, right or interests, in a cooperation and its activities, past, present and future” [4] cited in [2]. Stakeholders can be categorized in terms of how they interact with organizations, for example they can be internal, operate at the organizational interface or external [2]. Reference [4] refers to primary and secondary stakeholders and considers both as essential to the functioning of an organization. With respect to healthcare organizations, primary stakeholders can be viewed as patients, their families or next of kin, service users, clinical staff (e.g. nurses, medical doctors), administrative personnel and organizational leaders. The secondary stakeholders are those, who interact with the organization, but are not essential to the organizations existence such as voluntary groups or other support organisations.

14.2 Stakeholder Analysis

There is growing interest in the use of stakeholder analysis. This is reflective of the increasing awareness of how stakeholders, for example, groups and individuals can influence the decision-making process regarding the delivery, (in this instance) of healthcare and how individuals can inform and shape the nature of their own care and treatment.

A stakeholder analysis is an approach, a tool or set of tools for generating knowledge about individuals or organisations to better understand their behavior, intentions, inter-relationships and interests giving consideration to the influences and resources they bring to bear on decision making and/or implementation processes [2].

The purpose of a stakeholder analysis is to help understand stakeholders from the perspective of an organization or to determine the relevance of stakeholders to a particular research project, quality improvement project or policy. This can be particularly useful in identifying facilitators or barriers to the development of a research project or its implementation, the development of a health care service or implementation of a policy.

How to conduct a stakeholder analysis. A stakeholder analysis can be a useful tool when introducing a new policy or implementing policy recommendations as well as when embarking on changes to the health care delivery service, evaluating an initiative or other organizational changes. Getting the opinions of those that will be affected by the change is important to facilitate the success of the planned change/s. A stakeholder analysis is also helpful in identifying opportunities and threats to the proposed changes, which will assist with decision-making. Undertaking a stakeholder analysis involves a systematic approach utilizing a similar methodology to that of a research project. It will include aims/objectives, methodology, data collection, data analysis, discussion of findings in relation to existing data and dissemination as well as any limitations and/or implications.

When conducting a stakeholder analysis there are a series of steps to be followed beginning with questions to be considered before the analysis begins [2]. These include the context and scope (individual, organizational or national) of the analysis, what is its purpose, what are the aims and objectives of the analysis what methodology will be used to undertake the stakeholder analysis, how will the data be collected and analyzed, who will undertake the data analysis – a team or an individual? Consideration must also be given to the time frame (short or long) and this may depend on the budget available for the stakeholder analysis as well as the purpose. Other factors to be taken into account are how the findings will be presented, how any proposed change will be implemented and sustained and how any limitations of the stakeholder analysis will be presented. It is worth noting that conflicts can arise and that not all members of a team or organisation will favor a stakeholder analysis so strategies to manage such behaviors also need to be in place.

Changing philosophy in the delivery of healthcare. Across many health care systems the underpinning philosophy is changing from what was a traditional medical model to a more social approach. At organisational, team and individual levels this can present challenges as it calls for a change in culture and clinical practice. As part of this culture change greater emphasis is now given to person-centred-care [5], which fosters therapeutic relationships between clinicians, individuals and their significant others underpinned by values of mutual respect and individual right to self-determination. Shared decision-making is an essential part of this process and honours and values the voices of those with health care problems. It is predicated on enabling individuals to speak up during a clinical consultation as opposed to isolating people in their experience of suffering and resilience [6]. Enabling patients, carers and service users to contribute in this way increases their sense of self-worth, self-esteem and offers them a degree of ownership.

Stakeholder analysis of user involvement in resilient healthcare. This section will consider stakeholder analysis of user involvement in resilient healthcare with emphasis on mental health, but the approach is equally applicable to other areas of healthcare. There is a growing awareness that mental illness has a bearing on all aspects of society from individual experiences to wider economic impact. With this increasing awareness is the acknowledgement that those experiencing mental health issues should have greater input into the decision-making process about their care including service development although this is not always systematically conducted. Engaging service users in this way requires professional competencies and the communication skills that encourages service users to have a more active role in their own treatment and care [7]. Reference [8] highlight that patients, family and healthcare stakeholders are fundamental co-creators of resilience and the introduction of recovery oriented, person centered care provides such an opportunity. However, [9] indicated that inpatients reported few opportunities to have meaningful input into decision-making about their care. From the providers’ (stakeholders) perspective, patients’ were perceived as difficult to engage in care planning, goal setting and in meetings about treatment. Furthermore, [7] suggest that for service transformation to take place, providers need to understand and experience working with those undergoing mental health issues with mental health disorders in different roles and positions hence the importance of stakeholder analysis and the promotion of resilient healthcare.

To achieve greater service user involvement and greater integration we suggest a modified stakeholder analysis drawing on the approach of [2] for the organizational level and for the planning of individual care the work of [3]. Integrating these two approaches into the stakeholder analysis will ensure a stronger working relationship between the organisation and those it offers care to. Having the service users participate in this way will ensure a better match between the aspirations of both the individual and the organisation resulting in the stakeholder analysis being co-produced [10, 11]. Using a co-production approach enables service users/ patients to work in partnership with researchers, academics and/or clinicians. This partnership working can take a variety of forms including service users as researchers, or as members of advisory or steering groups. Prior to commencing a stakeholder analysis at the organizational level the benefits of such an exercise should be considered. Theoretically, the outcome should be that it will lead to enhanced service quality including better quality care, enhanced care outcomes, improved working relationships between practitioners and service users and overall improved care outcomes for the organisation.

As highlighted earlier when using the approach of [2] to conduct a stakeholder analysis a number of questions need to be addressed such as what is the context? This will depend on both the historical and contemporary culture of the organisation and its ethical principles. At what level with the analysis take place? This can take place at all organizational levels or more widely depending on the key questions as to why a stakeholder analysis is required. In order to conduct the analysis the stakeholders need to be identified and the best way to recruit them as well as consent to participate bearing in mind that not everyone maybe willing to take part. The nature and type of data that is required and the methods of its collection need to be agreed. Who will conduct the data analysis is a further consideration and can be either at team or individual level depending on the nature and objectives of the stakeholder analysis. The stakeholder analysis can be conducted by those internal to the organisation but also external, bearing in mind there are pros and cons to both. What will be the time line for the stakeholder analysis? For healthcare organisations this can be within a twelve month period or related to financial year returns. Other considerations are the reliability and validity of the data and any limitations of the stakeholder analysis; how the findings will be presented and by who needs to be addressed including the role of the service user participants as sometimes their contribution can be overlooked? Further important considerations of the stakeholder analysis are how the findings will be evaluated, used and any suggested changes implemented but this will depend on the objectives of the analysis.

Moving from stakeholder analysis at organisational level to the analysis at an individual level where the work of [3] will be considered as a framework. This framework highlights how individuals can be involved at different levels in the decision making process from their own treatment decisions to that of policy making and can act as a guide to individual involvement in stakeholder analysis making it more relevant to the lay public as they have a stake in the process. Within the framework there are three variables: (1) Decision-making domains (2) Role perspectives and (3) Level of participation. The decision making domains refer to treatment, service delivery and broad macro-or system-level decision-making. These subdomains are not entirely independent, for example the domain referring to treatment decisions takes account of the treatments/interventions that are available to patients whilst the second domain relates to resource allocation and the services that can be accessed and by whom in the defined locality. The third subdomain relates more to broader health care allocation and policy decisions at wider national levels.

The second variable in the framework is role perspectives where individuals can take on a variety of roles in the decision-making process including patient, advocate, peer-support worker, volunteer or policy maker. It is now better recognized that individuals can bring different perspectives to the health care decision-making process such as their role as a service user and a public policy perspective. Having the service user perspective can highlight concerns or benefits of any care decisions on health at an individual level, interest or support groups and the wider community. A public policy perspective takes on a much wider view and reflects a concern for the wider public good rather than specific more personal interests. The distinction is important because each role perspective incorporates different attitudinal assumptions and expectations, which individuals then bring to a particular decision-making context.

Focusing on the level of participation and the extent to which individuals have control over the decision-making process is the purpose of the third variable. In the literature there are a variety of terms used to describe the level of participation from consultation to service user control or service user led. Reference [3] state that in order to keep their framework manageable but at the same time capturing important distinctions in decision-making control, they collapsed their ladder into three categories: consultation, partnership, and lay control. These distinctions indicate the different level of patient participation in health care decision making. The framework acts as an analytic tool for conceptualizing key dimensions of lay involvement in health care decision-making. It provides a systematic structure for classifying a range of options available for lay participation in healthcare decision making and a useful template when conducting a stakeholder analysis around service user involvement in mental healthcare. Table 14.1 below offers a summary of the preparation and process for undertaking a modified stakeholder analysis.

Table 14.1 Modified stakeholder analysis: preparation and process

14.3 Results of a Stakeholder Analysis

With respect to the movement towards person-centred care and shared decision-making conducting a stakeholder analysis will give senior managers good insight into the opportunities and barriers towards change. It will highlight the organisations readiness for change and any education or managerial changes that need to take place and the pace at which the change should be introduced. Additionally, it will indicate the level of service user involvement in care decision-making, in all aspects of organisational activity and wider policy development. The overall outcome will lead to enhanced service quality including better quality care, enhanced care outcomes, improved working relationships between practitioners and service users and overall improved care outcomes for the organisation.

14.4 Conclusion

This chapter has explored the application of a modified stakeholder analysis in healthcare together with a conceptual framework focusing on lay participation in healthcare decision making. The importance of planning for a stakeholder analysis was indicated as well as the key questions that need to be considered beforehand including context and methodology. The role that patients and public can play in a stakeholder analysis was also considered along with benefits and potential results.