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Abstract
Healthcare systems are confronted with constant challenges and new crisis waves necessitating a transformation of current approaches to healthcare delivery. Transformation calls for integration, partnerships, interprofessional teamwork and collaboration between all healthcare stakeholders to create improved access and more personalised healthcare outcomes for patients. However, healthcare organisations are complex systems, comprising multiple stakeholders, and the existence of professional silos and functions which have varying degrees of interaction hampering the delivery of effective integrated healthcare. Research investigating the underpinning operations of how the various healthcare stakeholders integrate is lacking. To address this gap, the use of actor-network theory (ANT) can provide insight into underlying dynamics, interactions, interdependencies, governance processes and power dynamics of stakeholders in healthcare. ANT represents a suitable theoretical lens as it helps to appreciate the dynamics and underpinning behaviours of complex organisations and explains how networks are developed and how actors join networks and form associations. Our systematic review will identify and evaluate available evidence to understand the interplay between stakeholders and all associated entities that impact collaboration and integration in healthcare delivery.
Methods and analysis Using the Population-Intervention-Comparison-Outcome framework, the databases MEDLINE, CINAHL Complete, SCOPUS, PubMed, APA PsycINFO, Business Source Complete and Academic Search Complete will be searched using Boolean terms to identify peer-reviewed literature concerning ANT in healthcare. All relevant articles published between January 2013 and September 2023 will be eligible for inclusion. A thematic approach will be employed to appraise and analyse the extracted data to assess the various definitions of ANT and the use of ANT in healthcare settings, interactions and collaboration.
Ethics and dissemination Given that no primary data will be captured, ethical approval will not be required for this study. Findings will be shared and ultimately published through open access peer-reviewed journals and reports.
PROSPERO registration number 455283.
- PUBLIC HEALTH
- Health policy
- Primary Care
- Primary Health Care
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Strengths and limitations of this study
To our knowledge, our study represents the first systematic review of its kind to identify research on actor-network theory in a healthcare context and how it may be applied as a relevant approach to capture the dynamics of healthcare settings.
This study will contain a synthesis of recent studies and will therefore have the potential to inform future healthcare policy by guiding decision-makers through the complexities of actors and their respective networks across healthcare settings nationally/globally.
It was reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines.
This study is limited to studies published within the last decade to capture the most recent contextual developments, trends and advancements in the theory.
The protocol has a potential language bias as selected studies will be restricted to English and may lead to the exclusion of studies conducted in alternative languages.
Introduction
Research shows that collaboration and interprofessional teamwork, breaking down professional silos and sharing of information, and openness to change are core to achieving accessible integrated patient-centred healthcare. Taking actor-network theory (ANT hereafter) as a lens, this systematic review identifies, critically appraises and synthesises current literature on healthcare dynamics, behaviours and the interdependencies of the diverse range of individuals, groups and departments to provide evidence that supports effective collaboration and integration between key actors in healthcare.
Integrated healthcare systems
Globally, healthcare organisations are in a constant state of flux driven by the interplay of complex stimuli. For example, an ageing population, diverse profiles of users, chronic disease growth, technology and e-health, regulatory and governance issues, accountability and the increasing imperative for healthcare providers to deliver on objective of goal 3 of the Sustainable Development Goals (SDGs) to increase access and provide safe and effective health and well-being for all present challenges to the current bureaucratic models of public healthcare.1–4 Concurrently, patients are becoming more involved in decisions about their care reframing the patient and provider relationship to one based on partnership and mutual empowerment.5 Furthermore, healthcare organisations are grappling with shortages of healthcare professionals and talent retention issues6 which challenge both the leadership and the delivery of healthcare services. Consequentially, there is a focus on creating a more integrated healthcare system7–10 which is increasingly discussed and debated in research and policy with varying descriptors. At their core is a focus on people-centred health, collaboration and communication among health professionals, multidisciplinary teams working across discipline boundaries and sharing of knowledge and resources.
In a systematic review of integrated healthcare, Baxter et al 7 indicated that while models of integrated care were varied, they could largely be divided into four main categories. First, those with a focus on improving patient care directly; second, those focused on making changes to organisations and systems; third, ones focused on changing staff employment or working practices; and finally, those that addressed financial or governance aspects of integration.7
Integrated healthcare is in an emergent stage as are discussions on its impact or benefits with questions raised about integration efforts not materialising due to the bureaucratic nature of current models.11 Couturier et al concluded that drawing learnings from bureaucratic obstacles to integration could improve implementation strategies for integrated healthcare. The bureaucratic structures of current healthcare models embody numerous stakeholders with distinct roles, the existence of professional silos and functions that have varying degrees of interaction.12 Healthcare, departments and professions may compete for limited resources, power, status and recognition leading to a lack of sharing of information and collaboration.12–16 This controlled distribution of power between multiple actors results in resistance or slowness to change.11 These characteristics can lead to the erosion of trust among professionals, entrenched behaviours and a lack of teamwork or collaboration compromising the organisation’s productive culture.13 17 Such bureaucratic organisational structures, individual and group behaviours impact on interprofessional collaboration.18 Despite sharing the same goal of improving patient outcomes, professions and groups may have differing roles, and expectations about how care should be delivered.19 20 These characteristics are contrary to integration and fundamentally challenge the transition to agile operational models of integrated healthcare.
Healthcare is recognised as a complex multistakeholder system that finds change difficult as organisational actors are known to resist changes.11 To implement sustainable models of integrated healthcare it is necessary that the various stakeholders understand and value the skills and knowledge of each discipline to deliver accessible holistic patient care.21
Understanding what constitutes the characteristics of sustainable models of integrated healthcare is limited in research.22–24 Less research exists on good models of practice25 and research that investigates the underpinning operations of how the various stakeholders integrate.7 26 Furthermore, as healthcare is an adaptive system, where the system’s performance and behaviour changes over time requires an understanding of how its component parts or actors work together as opposed to individually.12
Addressing the above research gaps and considering the complexity of healthcare requires the adoption of theoretical approaches that deal with the complexity of the diverse stakeholder interactions in healthcare. The findings of the systematic review will assist in directing future research on the assessment of the impact of current integrated healthcare models, and the challenges and opportunities of integration which will serve to inform policy and practice on connecting the disconnect for integrated healthcare.
Actor-network theory
For this research, ANT is defined as a sociological theory that takes the fundamental stance that the world comprises hybrid entities which have both human and non-human elements.27 It directs focus on connections being made and remade between human and non-human entities called actants which share the role in network assembly.28 However, as ANT sees both human and non-human actors as equal within the confines of the network, assumptions are drawn that everything is connected. In essence, the only prerequisite for encompassing agency is being enrolled in a network itself. Therefore, ANT is deemed a relevant approach for several reasons. ANT is conceptually useful in helping to appreciate the dynamics and underpinning behaviours of the complexity of reality including the complexity of organisations.29 This further showcases the appropriateness of applying ANT within healthcare which is viewed as a complex organisational type. Furthermore, the use of ANT has the potential to foster comprehension of all components that should be accounted for and the relationship between them,30 which is imperative to comprehend for effective integration. ANT dismantles the pattern of interwoven and competing power relations31 to capture the underlying dynamics, interactions, interdependencies, decision-making processes and power dynamics of stakeholders and governance processes that impact the success of healthcare operations. While used in healthcare, the majority of studies to date lean towards understanding the implementation of information and communication technology (ICT) systems29 32; unpacking the complexities of public health interventions and healthcare operations,33 34 and research on the role of actors in e-health.35–37 These studies will provide a useful learning for the development of a protocol and subsequent systematic literature review.
This systematic review aims to identify, appraise and synthesise current evidence on the use of ANT in healthcare.
The aims of the systematic review include:
Identify and evaluate research on ANT in healthcare.
Assess the scope and quality of material reviewed to produce a contemporary detailed account of the evidence and learnings on the use of ANT in healthcare.
Generate a classification of dominant themes emerging from the review of the literature as to the use of ANT in healthcare settings.
Evaluate aspects of ANT in healthcare less researched and worthy of future research for changing dynamics of healthcare.
The subsequent systematic review will generate a focused research base on the application of ANT in healthcare as a means of establishing a strong theoretical foundation on which to identify what is known about the use of ANT in healthcare. The outcomes will identify the practices, challenges and opportunities for collaboration and the integration of actors in healthcare. In addition, the systematic review will identify areas for future research for advancing the effective implementation of new models of healthcare that have an integration or collaborative focus.
Methods and analysis
Search strategy
We will identify all relevant literature, with the presence of a publication date restriction to capture all recent developments and trends in ANT. Studies conducted, which are not published in English, will be omitted from the systematic review. Appropriate studies of interest will be identified by using medical literature databases. A comprehensive search of MEDLINE, CINAHL Complete, SCOPUS, PubMed, APA PsycINFO, Business Source Complete and Academic Search Complete was conducted (online supplemental file 1). EndNote V.X9 will be used to manage all references throughout the review process. We will use varying combinations of the Boolean phrases (box 1) to identify extant literature on the role/application of ANT in healthcare settings. In recognition of the significant role of human expertise when using the Boolean systems, specialists within the University library will be consulted to assist with the selection of the most appropriate terms for the aims of the review.38
Supplemental material
The Boolean phrases used for the systematic review search strategy.
Actor network theory AND healthcare OR health care OR hospital OR health services OR health facilities OR medical care.
Actor network Theory AND healthcare organization OR healthcare organisation OR healthcare system.
Actor network theory AND healthcare workers OR healthcare professional OR healthcare provider OR healthcare personnel OR doctor OR nurse.
Actor network theory AND healthcare professionals OR nurses OR staff OR healthcare workers.
Actor network theory AND allied health professionals OR allied healthcare professionals OR allied health workers OR professional or practitioner.
Actor network theory AND mental health professionals OR therapists OR counsellors OR psychologists OR social workers OR mental health nurse.
Actor Network Theory AND care of the elderly OR geriatric OR dementia OR end of life OR palliative care.
Actor Network Theory AND disability services OR accessibility services OR disability support services.
Actor Network Theory AND social care OR social services OR social work.
Actor network theory AND community healthcare workers.
Actor network theory AND acute healthcare worker.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses and PROSPERO
In line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015,39 we have completed the enclosed PRISMA-P checklist as online supplemental file 2. The final data analysis from the systematic review will be published in line with the preferred reporting structure for systematic reviews as outlined by Moher et al.40 This systematic review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO ID 455283; applied but awaiting decision). Any amendments in the final systematic review process will be published as part of the final document.
Supplemental material
Study design
Participant, Intervention, Comparison, Outcome, Study design
The eligibility, outlining the inclusion and exclusion criteria for the systematic review, will be guided by Participant, Intervention, Comparison, Outcome, Study design (PICOS) tool. The use of the PICOS tool provides a fully comprehensive search criteria for a systematic review which is crucial for validity, applicability and completeness.41 It will also seek to identify challenges that need to be addressed for enhanced patient care and to deliver on the imperatives of the objective of goal 3 of the SDGs to increase access and provide safe and effective health and well-being for all and address the many internal and external challenges facing healthcare organisations.
Participant (P)
This review will include studies that comprise working age participants who are 18 years of age or older and who are working as part of a healthcare system. As part of this population, we are concerned with identifying studies that focus on the uses and applications of ANT within a healthcare context.
Intervention (I)
Studies must meet the following criteria to be considered for the review:
Studies that discuss and outline the use and application of ANT within a healthcare context.
High-quality studies that are published in peer-reviewed journals.
Studies carried out in both public and private organisations.
To capture recent contextual developments, trends and advancements in the theory, a 10-year publication restriction will be used as part of the search criteria.42
Studies that examine the role of ANT in comprehending the dynamic and influence of human/inanimate actors within healthcare settings.
Studies that will be excluded are defined by:
Studies that do not focus on the healthcare setting.
Reviews, letters, opinion pieces and personal correspondence.
Articles in a language other than English.
Comparison (C)
Compared with studies that do not use ANT as the theoretical base for the paper.
Outcome (O)
The over-riding outcome of the review is to collate, synthesise and report the use of ANT in healthcare to provide a critical evaluation of the current evidence associated with the use of the theory within this context.
Unpack the complexity of the findings using the thematic analysis methodology to ensure the rigour and comprehensiveness of the review.
Research gaps within the literature will be delineated with future research opportunities suggested.
Study design/type (S)
This review will include all published peer-reviewed studies.
Data management
Data extraction will be undertaken independently by two reviewers using a structured data collection form. Where discrepancies occur, a third reviewer will be consulted. The process will commence with a screening of papers by their title and abstract and then a list of agreed titles will be collated from the extensive databases identified, and the results will be reported based on the PRISMA guidelines. Reasons for the exclusion of studies will be collected during the full-text screening phase.
Data extraction
Aligned with best practices, data extraction will be facilitated by a predesigned form to prompt the reviewers to extract standardised data based on the study design.43 If problems emerge in the data extraction process due to incomplete or differing reporting structures for data, the reviewers will attempt to contact the authors of the paper to clarify the findings. The data extraction reporting form will include the journal title, journal quartile, year of publication, article title, sample size, research methodology, measurements and key findings. One reviewer will pilot the extraction process using the developed form and one other reviewer will audit and agree to the process. Once complete, the form, including the agreed sample as a template for extraction, will be used by two reviewers who will extract the data independently. Discrepancies will be agreed on and discussed with the third reviewer.
Study timeframe
It is anticipated that the systemic review will commence in October 2023 and will be fully completed and ready for publication by April 2024.
Study selection and quality appraisal
First, all studies retrieved from the database search will be imported to EndNote V.X9. Two authors will independently review the literature for inclusion based on the title, abstract and keywords. The exclusion/inclusion criteria established above will guide each author’s decision as to whether the respective literature aligns with the parameters of the study. At this stage, literature which falls beyond the aims of the study will be removed. Excluded studies will be listed individually, accompanied with a justification for their exclusion. Any disagreements throughout the process will be discussed and resolved through consensus with the inclusion of a third independent author in the event of disagreements. This author will be available for involvement at any stage throughout the process to ensure our approach achieves and sustains transparency and balance. Subsequently, two authors will download and complete a full-text screening of potentially relevant literature to assess alignment with the aims of the study. In the event that duplicate studies are identified, they will be removed. Finally, each stage of the study selection process will be illustrated in accordance with the PRISMA statement.
Strategy for data synthesis
In line with the aims of the systematic review, a thematic review methodology will be used to extract and classify the dominant themes of ANT in healthcare research. This chosen methodology will also help to uncover the aspects of ANT in healthcare that are understudied and that warrant future research. The design of a thematic analysis is to uncover patterns in information or data.44 This type of analysis of qualitative data is an extensively useful and flexible method for analysing qualitative data.45 Qualitative methodologies are particularly applicable in healthcare settings as researchers try and make sense of the multiple complex processes.46 To ensure rigour in thematic analysis, a precise set of steps in data analysis must be followed.47 The findings from the included studies will be synthesised and reported using an inductive thematic analysis methodology as we are exploring the topic of ANT without preconceived categories or theories. Our thematic analysis will be in line with the six main steps described by Braun and Clarke,45 including: (1) understanding and identifying patterns in the data based on the research objectives outlined in the protocol; (2) developing initial open codes; (3) building open codes into meaningful themes and linking themes; (4) examining themes for accuracy; (5) refining and naming themes; and (6) generating the final systematic review report. Any significant limitations found within the data will be reported as part of the findings section. A complete interpretation of the results in terms of practical and theoretical contributions will be discussed in the subsequent systematic review once complete with recommendations for further research suggested.
Patient and public involvement
The purpose of this study protocol is to provide a detailed plan for a systematic review designed to inform decision-making at a health system level in relation to organisation and competency development for healthcare actors and the networks they operate it. Given that patient and public involvement (PPI) forms a central tenet of most policy requirements in health and social care services,48 this protocol included PPI input, specifically the protocol structure, and the draft manuscript was commented on and coauthored by a senior clinician working within a healthcare network. Senior clinicians working as part of a PPI committee can provide valuable insights and expertise and can ensure the research is addressing real-world clinical needs. As a cohort, they bridge the gap between research and clinical practice, helping to inform health policy which can lead to improved healthcare strategies.49 50
Ethics and dissemination
Given that no primary data will be captured, ethical approval will not be required for this study. Intention exists for the findings to be shared and ultimately published through open access peer-reviewed journals to reduce access barriers for stakeholders within and beyond academic institutions/contexts. Findings will be further disseminated to diverse audiences at national and international conferences. Furthermore, a link to the published systematic review will be shared across social media platforms to reach the non-academic cohort. Findings may also be presented via webinars to reduce barriers to access and enhance awareness to potential international audiences.
Discussion
This protocol clearly outlines rigorous steps for the development of a systematic review which will bring forth an extensive overview of the role of ANT as a lens through which healthcare settings can be viewed and ultimately understood. As healthcare settings internationally are underpinned by the complexities of their diverse range of stakeholders, it is imperative to appreciate the associated dynamics and how such stakeholders, both human and inanimate, influence their respective networks at a structural and operational level. Such dynamics exacerbate the prevalence of comprehending healthcare configurations and how stakeholders’ interactions contribute to the overall functioning of any healthcare setting. Therefore, this review will facilitate the compilation of all relevant literature to unpack the use of ANT and its capacity to contribute to knowledge on the components that dictate the functioning of healthcare settings. Consequentially, this review will draw on empirical evidence that can inform policy with regard to the barriers and enablers of adopting an integrated approach. This review can also help guide decision-makers and derive positive implications across all levels of healthcare with the evidence base providing a platform to develop frameworks for best practice across all streams of healthcare. In addition, our review holds the potential to assist researchers and clinicians to positively influence patient-level outcomes. In this sense, the review will provide a pathway to divulge existing evidence surrounding the applicability of ANT within healthcare settings and how its conceptual orientation can help assimilate its associated components. In turn, the duality of the process will enable in-depth analysis of network complexities allowing stakeholder relationships to be considered, analysed and subsequently maximised for mutual benefit.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors TR, BH and NR conceived the idea for this systematic review. All authors (TR, BH, NR and AF) developed the methodology for the systematic review. TR and NR constructed the search strategy. TR, BH and NR wrote the manuscript. All authors (TR, BH, NR and AF) critically revised and assessed the final manuscript.
Funding This work was supported by the Health Service Executive in the Mid-West Region of Ireland.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.