Scoping studies are an increasingly popular approach to reviewing health research evidence. In 2005, Arksey and O'Malley published the first methodological framework for conducting scoping studies. While this framework provides an excellent foundation for scoping study methodology, further clarifying and enhancing this framework will help support the consistency with which authors undertake and report scoping studies and may encourage researchers and clinicians to engage in this process. We build upon our experiences conducting three scoping studies using the Arksey and O'Malley methodology to propose recommendations that clarify and enhance each stage of the framework. Recommendations include: clarifying and linking the purpose and research question (stage one); balancing feasibility with breadth and comprehensiveness of the scoping process (stage two); using an iterative team approach to selecting studies (stage three) and extracting data (stage four); incorporating a numerical summary and qualitative thematic analysis, reporting results, and considering the implications of study findings to policy, practice, or research (stage five); and incorporating consultation with stakeholders as a required knowledge translation component of scoping study methodology (stage six). Lastly, we propose additional considerations for scoping study methodology in order to support the advancement, application and relevance of scoping studies in health research. Specific recommendations to clarify and enhance this methodology are outlined for each stage of the Arksey and O'Malley framework. Continued debate and development about scoping study methodology will help to maximize the usefulness and rigor of scoping study findings within healthcare research and practice.

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Scoping studies: advancing the methodology

Scoping reviews are a relatively new approach to evidence synthesis and currently there exists little guidance regarding the decision to choose between a systematic review or scoping review approach when synthesising evidence. The purpose of this article is to clearly describe the differences in indications between scoping reviews and systematic reviews and to provide guidance for when a scoping review is (and is not) appropriate. Researchers may conduct scoping reviews instead of systematic reviews where the purpose of the review is to identify knowledge gaps, scope a body of literature, clarify concepts or to investigate research conduct. While useful in their own right, scoping reviews may also be helpful precursors to systematic reviews and can be used to confirm the relevance of inclusion criteria and potential questions. Scoping reviews are a useful tool in the ever increasing arsenal of evidence synthesis approaches. Although conducted for different purposes compared to systematic reviews, scoping reviews still require rigorous and transparent methods in their conduct to ensure that the results are trustworthy. Our hope is that with clear guidance available regarding whether to conduct a scoping review or a systematic review, there will be less scoping reviews being performed for inappropriate indications better served by a systematic review, and vice-versa.

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Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach

The 2008 crash has left all the established economic doctrines - equilibrium models, real business cycles, disequilibria models - in disarray. Part of the problem is due to Smith’s "veil of ignorance": individuals unknowingly pursue society’s interest and, as a result, have no clue as to the macroeconomic effects of their actions: witness the Keynes and Leontief multipliers, the concept of value added, fiat money, Engel’s law and technical progress, to name but a few of the macrofoundations of microeconomics. A good viewpoint to take bearings anew lies in comparing the post-Great Depression institutions with those emerging from Thatcher and Reagan’s economic policies: deregulation, exogenous vs. endoge- nous money, shadow banking vs. Volcker’s Rule. Very simply, the banks, whose lending determined deposits after Roosevelt, and were a public service became private enterprises whose deposits determine lending. These underlay the great moderation preceding 2006, and the subsequent crash.

The Economic Institutions of Capitalism

Reviews of primary research are becoming more common as evidence-based practice gains recognition as the benchmark for care, and the number of, and access to, primary research sources has grown. One of the newer review types is the 'scoping review'. In general, scoping reviews are commonly used for 'reconnaissance' - to clarify working definitions and conceptual boundaries of a topic or field. Scoping reviews are therefore particularly useful when a body of literature has not yet been comprehensively reviewed, or exhibits a complex or heterogeneous nature not amenable to a more precise systematic review of the evidence. While scoping reviews may be conducted to determine the value and probable scope of a full systematic review, they may also be undertaken as exercises in and of themselves to summarize and disseminate research findings, to identify research gaps, and to make recommendations for the future research. This article briefly introduces the reader to scoping reviews, how they are different to systematic reviews, and why they might be conducted. The methodology and guidance for the conduct of systematic scoping reviews outlined below was developed by members of the Joanna Briggs Institute and members of five Joanna Briggs Collaborating Centres.

Guidance for conducting systematic scoping reviews.

Doing Qualitative Research

Scoping studies have been used across a range of disciplines for a wide variety of purposes. However, their value is increasingly limited by a lack of definition and clarity of purpose. The UK's Service Delivery and Organisation Research Programme (SDO) has extensive experience of commissioning and using such studies; twenty four have now been completed. This review article has four objectives; to describe the nature of the scoping studies that have been commissioned by the SDO Programme; to consider the impact of and uses made of such studies; to provide definitions for the different elements that may constitute a scoping study; and to describe the lessons learnt by the SDO Programme in commissioning scoping studies. Scoping studies are imprecisely defined but usually consist of one or more discrete components; most commonly they are non-systematic reviews of the literature, but other important elements are literature mapping, conceptual mapping and policy mapping. Some scoping studies also involve consultations with stakeholders including the end users of research. Scoping studies have been used for a wide variety of purposes, although a common feature is to identify questions and topics for future research. The reports of scoping studies often have an impact that extends beyond informing research commissioners about future research areas; some have been published in peer reviewed journals, and others have been published in research summaries aimed at a broader audience of health service managers and policymakers. Key lessons from the SDO experience are the need to relate scoping studies to a particular health service context; the need for scoping teams to be multi-disciplinary and to be given enough time to integrate diverse findings; and the need for the research commissioners to be explicit not only about the aims of scoping studies but also about their intended uses. This necessitates regular contact between researchers and commissioners. Scoping studies are an essential element in the portfolio of approaches to research, particularly as a mechanism for helping research commissioners and policy makers to ask the right questions. Their utility will be further enhanced by greater recognition of the individual components, definitions for which are provided.

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Asking the right questions: Scoping studies in the commissioning of research on the organisation and delivery of health services

Objective : To study the processes involved in and impact of mergers between NHS trusts, including the effect on management costs. Design : Cross sectional study involving in depth interviews and documentary analysis; case study to compare savings in management costs between case trusts and control trusts. Setting : Nine trusts (cross sectional study) and four trusts (case study) in London. Participants : 96 interviews with trust board members, other senior managers, clinicians, service managers, and representatives of health authorities, regional office, community health councils, local authorities, other trusts in the area, and primary care groups and trusts. Main outcome measures : Stated and unstated drivers, and impact of merger on delivery and development of services, management structures, and staff recruitment, retention, and morale. Effects of difference in trust size before and after the merger. Savings in management costs two years after merger. Results : Some important drivers for merger are not publicly stated. Mergers had a negative effect on delivery of services because of a loss of managerial focus on services. Planned developments in services were delayed by at least 18 months. Trusts9 larger sizes after mergers had unintended negative consequences, as well as predicted advantages. The tendency for one trust9s management team to dominate over the other resulted in tension. No improvement in recruitment or retention of clinical and managerial staff was reported. Perceived differences in organisational culture were an important barrier to bringing together two or more organisations. Two years after merger, merged trusts had not achieved the objective of saving £500 000 a year in management costs. Conclusions : Important unintended consequences need to be accounted for when mergers are planned. Mergers can cause considerable disruptions to services, and require greater management support than previously acknowledged. Other organisations undergoing restructuring, such as primary care groups developing into primary care trusts and health authorities merging into strategic health authorities, should take these findings into account.

https://www.bmj.com/content/bmj/325/7358/246.full.pdf

Process and impact of mergers of NHS trusts: multicentre case study and management cost analysis

In the last decade, explicit priority setting has become an integral part of health care systems. Indeed, there is even an International Society on Priorities in Health Care, created in 1997 (Ham 1997). Whether it is Oregon's priority ordering of symptom treatment pairs to maximize the impact of a limited Medicaid budget (Fox and Leichter 1991), England's National Institute for Clinical Excellence's assessing priorities for therapeutic innovations in the National Health Service (Rawlins 1999), or New Zealand's setting priorities for patients’ access to cardiovascular treatment (Hadorn and Holmes 1997), techniques for judging the relative worth of different health service investments abound.

As these techniques are refined, the most common addition is the incorporation of public values as part of the assessment. Priority setting is increasingly seen as combining an objective assessment of costs and effects with a more subjective assessment of patient or public preferences (Lenaghan, New, and Mitchell 1996; Lomas 1997; National Institute for Clinical Excellence 2002; Stronks et al. 1997).

The incorporation of the service users’ values has led some commentators to conclude that the process is more important than the science. For instance, Klein declared:




Given conflicting values, the process of setting priorities for health care must inevitably be a process of debate. It is a debate, moreover, which cannot be resolved by an appeal to science and where the search for some formula or set of principles designed to provide decision-making rules will always prove elusive. Hence the crucial importance of getting the institutional setting of the debate right … the right process will produce socially acceptable answers—and this is the best we can hope for.

(Klein and Williams 1999, 20–21)




Our article is a response to Callahan's recent observation that “the effort to devise priorities for health care systems is far more advanced and sophisticated than for biomedical research. With the exception of the NIH, it is hard to discover much extended debate anywhere in the world on how best to prioritize research” (Callahan 1999, 116). We describe how the lessons learned from and the approaches to setting priorities for funding health services are translated into setting priorities for funding health services research, in which the paymasters want to use the finite human and financial resources for those areas most likely to improve health services delivery.

We agree with Klein's and Callahan's views that getting the priority-setting process right—preventing domination by any particular interest, being transparent, and reflecting the values of all relevant users—is the most important consideration. Their approaches also reflect the emerging importance of involving users and their values in the process. In the case of research, however, the users include not only patients and providers but also managers and policymakers striving to make the best possible decisions in an evidence-based health service (Walshe and Rundall 2001).

We begin with a review of previous approaches to setting priorities for health research and then state the case for the greater involvement of research users, at least for applied health services research. We use two case studies—one in England and one in Canada—to describe a “listening model” for setting user-driven health services research priorities. Finally, we draw lessons from the case studies before concluding that setting priorities for health services research is more an interpretive than a technical exercise.

/pdf/on-being-a-good-listener-setting-priorities-for-applied-xisaimdd9t.pdf

On being a good listener: setting priorities for applied health services research.

Changing organisations: a study of the context and processes of mergers of health care providers in England.

This is the second in a series of five articles 

Accountability is at the heart of the concept of clinical governance. Not only must health professionals strive to improve the quality of care, they must also be able to show that they are doing so.

The notion of accountability is not new—clinicians have long been accountable to their professional regulatory bodies. However, recent scandals about dangerous practice by doctors have damaged confidence in the current system of peer-led self regulation and raised concerns about the limited accountability of doctors in particular. 1 2 The new requirement for primary care clinicians to be answerable to colleagues in their practice and their primary care group or trust can be seen as one of a range of responses to these concerns and is central to the notion of clinical governance.

This paper will discuss how the notion of accountability in clinical governance can be understood and operationalised within primary care. It will use the clinical governance work of a London primary care group as a case study to illustrate mechanisms of accountability and will show how there are different forms of accountability between health professionals and others, relating to various aspects of performance. The paper will also consider the barriers to improved accountability and highlight tensions that are likely to arise.

#### Summary points

Clinical governance will extend primary health care professionals' accountability beyond current forms of legal and professional accountability

Clinical governance in primary care is aimed at enhancing the collective responsibility and accountability of professionals in primary care groups or trusts

It is mainly concerned with increasing the accountability of primary health professionals to local communities (downwards accountability), the NHS hierarchy (upwards accountability), and their peers (horizontal accountability)

Primary care groups and trusts may find that, in addition to encouraging a …

https://www.who.int/management/partnerships/accountability/ClinicalGovernancePHCAccountability.pdf

Pauline Allen

Papers

Asking the right questions: Scoping studies in the commissioning of research on the organisation and delivery of health services

Process and impact of mergers of NHS trusts: multicentre case study and management cost analysis

On being a good listener: setting priorities for applied health services research.

Changing organisations: a study of the context and processes of mergers of health care providers in England.

Accountability for clinical governance: developing collective responsibility for quality in primary care.