Protocol for a scoping review of work system design in health care

Background: Delivery of safe and reliable healthcare to patients and the healthcare workforce shortage amidst growing demand has been major challenge to the healthcare system. Addressing this challenge calls for designing or redesigning of healthcare work system. Work system design which is usually associated with productivity in manufacturing offers a wide spectrum of applicability in addressing this challenge of healthcare system. Despite the availability of primary studies on work system design in healthcare, there are sparse published reviews in specific contexts. This scoping review explores the existing evidence to understand the state of the art of work system design in healthcare. Methods: The scoping review adopts the methodology of Joanna Briggs Institute for scoping review which is based on the methodological framework of Arksey and O’Malley. The search will be done on PubMed, Scopus, and Web of Science for the identification of eligible studies. A grey literature search will also be performed. A two-phase screening and extraction of data will be done by two independent reviewers. Data extraction will be done on a pre-piloted data extraction form. The findings will be presented in tables, figures, and a narrative summary. The scoping review will highlight the state of the art, gaps in knowledge and provide directions for future research. Ethics and dissemination: This is a scoping review of primary studies and therefore ethical approval is not required. The report of the findings will be presented in line with the PRISMA reporting guidelines for scoping reviews (PRISMA-ScR). The results will be submitted to a peer-reviewed scientific journal for publication and presented at relevant conferences.


Introduction
The provision of safe and reliable healthcare for patients with an adequate and accessible health workforce is the bedrock of an efficient and effective healthcare work system.The ability of the healthcare system to deliver safe and reliable healthcare to patients is vital to earning public trust. 1Delivery of safe and reliable healthcare to the patient has been a challenge due to ineffectiveness and inefficiencies in the performance of the healthcare work system thereby resulting in patient's safety problems.
Adequate and accessible health workforce is fundamental to an integrated and effective health system and provision of care.However, there is a global projection of a shortfall of 15 million health workers by 2030, with a major proportion in the low and middle-income countries. 1Poor design of the healthcare work environment also contributes to the shortage of health workers.For example, the shortage of nurses has been linked to the inability to attract and retain nurses because of poor working condition. 2,3Carayon et al. (2012) 4 argue that the working conditions of healthcare professionals and workers are sources of stress, burn out and dissatisfaction.Poor infrastructure, unsafe environment, and unfair distribution of incentives among other factors are accountable for poor working conditions of health care personnel. 5dressing these challenges call for a designing or redesigning of healthcare work systems for improved performance.8][19][20] But the concept of "system" from the Industrial and Systems Engineering point of view, as positioned by Carayon et al. 4 refers to "various elements of work that healthcare personnel use, encounter or experience in order to perform thier jobs".The system approach considers all elements of the system and their interconnections as well as the system's layout in ensuring the achievement of the system goal(s). 21typical work system comprises elements that interact with each other to achieve the desired outputs.The elements include tasks, tools, technology, work organisation, environment of work and humans.Kleiner 22 remarks that in work system, humans are employed to carry out some defined task as teams, and interact with the technology within an environment.Edwards and Jensen 23 identify workers, technology, facilities, formal and informal organizations as the entities of a work system.Five elements of work system as given by Smith and Sainfort 24 with respect to balance theory are tools and technologies, human, physical environment, tasks and the organization.The interface and relationship that exist among these entities gives the desired outputs.Wilson 25 argues that the interactions between people, task, equipment and environment are critical in addressing the work system performance and safety issues.Understanding the elements of healthcare work system and their interactions is important in its design or redesign.
Work system design has been influenced by organizational theoretical views of classic and human relation theory 22 as well as balance theory 24 which supported the integration of classic and human relation theory.Work system design is rooted in socio-technical system theory which posit that the improvement on design and performance of a system is achievable only if there is interconnection and integration of social and technical aspect of work system. 10rk system design (WSD) involves a systematic approach that considers various components that make up the work system.It aims at minimizing or eliminating the negative aspects of work which contribute to the poor performance of the work system. 4Work system design ensures that the work environment is designed for workers to have optimal workload, human safety, health and well-being ensured and optimal overall system performance. 26The design of work systems has benefited greatly from the principles, theories, tools and techniques of Human Factors, Systems and Method Engineering.Human Factors Engineering has been identified by the National Academy of Engineering and the Institute of Medicine as an important tool for designing better healthcare systems. 4,27This suggests that work system design is a robust tool which

REVISED Amendments from Version 1
The revised version reviewed RQ2 to increase clarity and the background of the study was strengthened by providing the overview of the work system as suggested by one of the reviewers.
has potential in improving the healthcare system.However, there is a need to investigate work system design approaches that have been used in health care.
Despite the availability of primary research studies on work system design in healthcare, there are sparse published reviews.Also, published reviews considered specific context in the application of work system design to healthcare.For instance, reviews have explored the use of human factors and ergonomics approach to work system design in healthcare. 28,29Also, a review has demonstrated the use of the Systems Engineering Initiative for Patient Safety (SEIPS) model to improve patient work. 30To the best of our knowledge, a review with focus on work system design in healthcare in a broader context has not been conducted.A comprehensive understanding of work system design in healthcare is vital to exploring its approaches to addressing the challenges of the healthcare system.Consistent with scoping review which is known for mapping out the body of literature on a topic area, 31 this scoping review aims to explore the existing evidence to understand the state of the art of work system design in healthcare.To achieve this aim, the review objectives are: 1. to report work system design approaches in healthcare 2. to identify areas where it has been applied in healthcare 3. to identify gaps for further research and make recommendations for future research.

Protocol design
The scoping review adopts Joanna Briggs Institute (JBI) scoping review methodology which is based on the methodological framework of Arksey and O'Malley. 32,33The methodology has 6 stages which are as follows: Stage 6 of the methodology, although optional, is valuable if it can be explored.This scoping review will not consider it because of constraints of budget and time.Also, the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping reviews (PRISMA-ScR) checklist was followed in preparing the protocol.

Identifying the research questions
The research questions were developed using the iterative process of Arksey and O'Malley through consultation with the team and the team came up with the following questions: (1) What are the work system design approaches used in healthcare?(2) How have work system design interventions been applied in healthcare?(3) What are the gaps in the existing literature and recommendations for future studies with respect to work system design in healthcare?
Identification of relevant studies Population, Concept, and Context (PPC) framework was used to determine relevant terms and studies. 32The search will identify all studies without any restriction to date and geographical location.The search will be implemented across three electronic databases: PubMed, Scopus, and Web of Science.These databases were selected for comprehensiveness and coverage of a broad range of disciplines.The search strategy consists of keywords generated from related studies and are approved by all authors to describe the scoping review and its methodology: work system design, work system, systems engineering, human factors, work design, workplace design, job design, organisation design, macroergonomics, work organisation, time and motion study, healthcare, health system, health care.The preliminary search on PubMed (see Table 1) combines keywords with Boolean operators.This will be adapted for search in other databases in consultation with a librarian.
The same search strategy will be used for a web search to be conducted on Google Scholar to identify grey literature.In consideration of screening time for each hit and the likelihood of not yielding many more relevant articles, the decision to screen only the first 50 hits was made.Other identified websites such as National Academy of Engineering, Ergonomics and Human factors organization will be manually searched.The studies to be included in this scoping review must meet the following inclusion and exclusion criteria as depicted in Table 2.
The Population/Concept/Context (PCC) framework is outlined to guide in the identification and screening of relevant studies.The population which identifies important characteristics of participants is not applicable to this study.The concept is focused on exploring the existing evidences in understanding work system design approaches as applied to healthcare.Primary studies on work system design in healthcare will be included.All reviews articles whether literature or systematic will be excluded.The context for the scoping review is global and studies in the English language only will be included while all studies in other languages will be excluded.There is no date limit to this study.

Selection of eligible studies
The screening process is in two phases; screening of titles and abstracts and screening of full texts.Two independent reviewers will carry out screening of titles and abstracts, to select studies that are in line with PPC framework as given in the inclusion and exclusion criteria.Full-text screening which is the second phase of screening process is to be done by two independent reviewers to select studies that met the inclusion criteria for this scoping review.At this phase, full-text studies will be excluded if they do not meet inclusion requirements and the reason for excluding the studies will be provided in the final report.Data generated by two independent reviewers will be extracted, assessed and discussed.The report of the final results of the search will be presented following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram.Disagreements in the selection process by the two independent reviews will be resolved through dialogue or a third-party reviewer.A consensus approach will be used in resolving disagreement if any exists.However, if this is not achieved, a third reviewer will be consulted.

Data extraction
Data extraction gives a descriptive summary of study results to address scoping review objectives and research questions.Excel spreadsheet was used in the development of a template for data extraction.The validity of the template will be piloted and tested prior to the commencement of data charting.Key information to be extracted include authors, year, title, journal, study objectives, study setting, and study site, to mention a few.Table 3 gives the data charting framework for this scoping review.A data extraction form will be used for the collection of general information from relevant studies and data that will be helpful in answering the research questions.Data extraction will be done by independent reviewers and consensus will be reached by team members on resolving discrepancies.Revision and update will be done on the data extraction form during the review process to accommodate necessary changes.#2 TITLE-ABS (healthcare OR "health care" OR "health system" OR "healthcare systems") #1 TITLE-ABS ("work system design" OR "work system" OR "systems engineering" OR "work design" OR "workplace design" OR "job design" OR "organizational design" OR macroergonomics OR work AND organization AND time OR "motion study")

Data synthesis strategy
The collation of findings from the data extraction form will be analysed using themes relating to the review objectives.Descriptive analysis to summarize the characteristics of the included studies such as publication year, study setting and site and also the evidence on the approaches of work system design in healthcare, the area of its applications in healthcare and the limitations of the approaches and application of work system design in healthcare.On the other hand, areas that are not well-researched and may require further investigation will also be highlighted.Results will be presented in form of tables and figures where appropriate.Also, a narrative summary of the findings will be presented.
This study will explore the existing evidences to understand the state of the art of work system design in healthcare.It aims to provide the breadth and depth of work system design knowledge as an important tool for designing better healthcare systems.It will also identify gaps in knowledge and provide directions for future research.

Study status
Currently developing and piloting data extraction form, and the next step will be running of the search and screening at a later date.

Dissemination
The report of the findings will be presented in line with the PRISMA reporting guidelines for scoping reviews (PRISMA-ScR).The results will be submitted to a peer-reviewed scientific journal for publication and presented at relevant conferences and events.

Data availability
No data are associated with this article.

Irwan Budiman
Universitas Prima Indonesia, Medan, North Sumatra, Indonesia The objectives to be achieved have been well described and the protocol developed can achieve the expected goals.But, please re-check the keywords for the more suitable to this research.Macroergonomics is closely related to the discussion of ergonomics which focuses on the structure and organization of work direction related to tasks, content, and time factors.Structural reporting flow can be done from the operational level to the functional level, or from the functional level to the strategic / business level in health care.It would be better if the described work system improvements in health care were organized systematically up to the reporting flow.The method has also been compiled quite well.However, it would be better if the method can be described in more detail so that it can be easily replicated by others.
Datasets have been presented in full.
Is the rationale for, and objectives of, the study clearly described?Yes

Are the datasets clearly presented in a useable and accessible format? Yes
Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Macroergonomics and Ergonomics Work System Design
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

E.H.E. Europa Hochschule EurAka CH, Therwil, Switzerland
Overall, the core structure and contents of this protocol seem sound.
The article requires some further proofreading to improve readability and amend some sparse typos and/or improve the editing.I believe that there is need and scope to improve the protocol by considering the following points: The introduction proposes a valid emphasis on "work system design".However, I would recommend strengthening the background, by introducing an overview of the work system theory, in order to better contextualize the reader by explaining what a work system is, what the involved elements and relationships are, and why their perspective is important in healthcare practice.
○ By focussing on "application areas" RQ2 seems to me overly vague, and it can lead to difficulties in analyzing data from the review.It seems to me that this scoping review warrants a systematic examinations of applications of work system design (WSD) in healthcare, and that "application areas" can be one of the multiple analyses to be done based on the "application data" extracted from the reviewed studies.Other analyses should then ensue, such as, for example, how many studies have empirically corroborated the effects of WSD, types of effects ascertained, etc.A deeper and better structured analysis along these lines would then facilitate the identification of trends and gaps in current research, and the subsequent proposal of orientation for future research.

○
The authors indicate that data extraction will be based on a pre-developed template, and that "The validity of the template will be piloted and tested prior to the commencement of data charting".This is somewhat confusing to me: Firstly, what do the authors mean by "charting"?If this is about identifying and classifying excerpts in the original texts based on predefined categories, then this would sound to me like a data coding procedure appropriate to extract data prior to analysis (e.g., identifying all the excerpts describing which elements of a work system have been redesigned, to later on propose a synthesis highlighting which elements have been more frequently addressed, by how many studies, etc.)If "charting" means something else to the authors, then it should be clarified and justified.
(b) Secondly, the authors should clarify how they intend to "pilot and test" the template prior to the commencement of the data extraction process.I would also consider that data extraction templates do not need to be "fixed" a-priori.

Cecilia Berlin
Div. of Design & Human Factors, Chalmers University of Technology, Gothenburg, Sweden This protocol for a scoping review aims to broadly map out the scope of available work (system) design literature that is applicable to healthcare settings.Its intention, aim, proposed methodology and intended further steps are detailed and described in a sensible and mostly satisfactory way.I think the forthcoming paper sounds promising and I would be interested to read it.
The protocol (and its subsequent paper) will benefit from a thorough language check.The way this is written, I have a feeling that the authors are competent writers, but there are some incorrect singular/plural noun choices, and sentence structure errors here and there that could be edited for clarity, mostly by reducing length and complexity.One example is the first sentence of the 3rd paragraph ("Addressing these...").
Research question 2 should grammatically be written, "Which areas have work system designs been applied _to_ in healthcare?".I would however suggest that "areas" is rather vague in this sense, so I would like to suggest "How have work system design interventions been applied in healthcare?".In this way, the focus can be placed on reporting intervention studies and empirical findings in RQ2.However, this is just a suggestion to increase clarity.
In your search terms, remember that there may be some variation in whether it is called "system engineering" or "systems engineering".I might also recommend searching "sociotechnical systems" and "socio-technical systems".
Is the rationale for, and objectives of, the study clearly described?Yes Is the study design appropriate for the research question?Yes Are sufficient details of the methods provided to allow replication by others?Yes Are the datasets clearly presented in a useable and accessible format?

Not applicable
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Production ergonomics, social sustainability, work system design, human factors in manufacturing, macroergonomics, cognitive ergonomics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
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Stage 1 .
identification of the research question; Stage 2. identification of relevant studies; Stage 3. selection of eligible studies; Stage 4. charting the data; Stage 5. collating, summarising and reporting the results; Stage 6. consultation with stakeholders, Report 01 August 2023 https://doi.org/10.5256/f1000research.141552.r185072© 2023 Fabricatore C.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

○I
would recommend reporting (and further detailing) the systematic literature search protocol based on the PRISMA-S statement (Rethlefsen et al., 2021 1 ), in order to improve the replicability of the search.

Table 2 .
Inclusion and exclusion criteria.

Table 1 .
Search strategy for PubMed.
They may be modified through iterative processes of data extraction and coding, e.g., as suggested by the template analysis technique (King, 2012 2 ).Consider discussing the broader relevance of the protocol: does it represent a contribution in and of itself?Can it be useful to guide other reviews?Thank you for your comments.The background of this study has been strengthened as suggested.RQ2 has been reviewed.The PRISMA-S as given byRethlefsen et al. (2021)may not be applicable to the study because it is meant for reporting systematic review.PRISMA-ScR as stated in the protocol is appropriate PRISMA reporting guidelines for scoping review.The charting refers to data extraction, one of the six stages of the scoping review methodology."pilot and test" template prior to the commencement of data extraction process is to ensure the validity of the process.This will be carried out on a of included studies in order to ensure consistency in the use of the framework for data extraction and if need be, the data extraction framework can be modified ○ Reviewer Report 04 July 2023 https://doi.org/10.5256/f1000research.141552.r179129© 2023 Berlin C.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.