Investigating the use of actor-network theory in healthcare: a protocol for a systematic review

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.