Concept analysis can be viewed as the means of establishing conceptual clarity about a phenomena of interest (6), and this inquiry method has evolved in healthcare because it is widely thought that a discipline is responsible for building its scientific research base from a set of well-developed key concepts pertaining to its area of interest (7). There are many methods and approaches to concept analysis, and a researcher should choose his based on the analysis objectives and concept maturity. A PubMed search of the term ‘Health System Resilience’ on June 16, 2021, yielded 4704 entries, with most of the articles published in the past 10 years (Fig. 1). Because of the relatively small number of articles, we determined that the concept is not mature yet. Therefore, we followed the Schwarz-Barcott and Kim’s hybrid model and carried out a ‘concept analysis’ review, identifying the attributes, precedents, and consequences (8). This paper will present the initial phase of Schwarz-Barcott and Kim’s Hybrid model, which consists of theoretical, fieldwork and final analytical phases.
Clearly defined concepts are the basic building blocks of theories and knowledge in science and are used to establish a common understanding of a phenomenon across disciplines. Concepts can be poorly defined, poorly understood, unambiguous, and undeveloped was used in the nursing literature to “enhance the understanding of a concept beyond a simple dictionary definition” and by definition clarifies meanings by conducting research using intellectual analysis. ‘Concept analysis’ is employed through various approaches: concept development, concept delineation, concept comparison, concept clarification, concept correction, or concept identification (9–11).
Several methods have been used in the literature for ‘concept analysis’. The most common, yet widely criticized, is the Wilson method. This method and others branching from it, otherwise commonly named “Wilsonian methods”, had been implicated as overly simplistic, lacking in scientific rigour, and limited operational use. They also depend on case scenarios, which may not always be applicable, or represent the phenomenon discussed. Another commonly used framework is Morse’s and Rodgers’ evolutionary method. Morse proposes the idea of ‘concept maturity’ and considers the evaluation of concept maturity a prerequisite for concept analysis (9, 12, 13). Evaluating ‘concept maturity’ before choosing a concept analysis method is suggested. Evaluation of ‘concept maturity’ is a subjective evaluation that considers the clarity of the concept definitions, characteristics, preconditions, outcomes, and delineated boundaries.
For health system resilience, a preliminary PubMed search on June 29, 2020, using the keywords “resilience health system” and “resilient health system” showed 3510 and 1772 entries, respectively, where the oldest publication was in 1977. Morse 1995 recommends that immature concepts, such as health system resilience be analysed through a literature review, identifying attributes, verifying them, and identifying manifestations of those attributes. We have chosen to use the hybrid model by Schwarz-Barcott and Kim for this concept development review (14).
Objectives: In this review, we aim to identify the health systems resilience definitions, attributes, antecedents, and consequences and thus have a better understanding of what health system resilience is as a concept, after which we will develop a framework to identify the domains that could constitute a measure. It is not our aim to develop a scale for health system resilience in this paper.
Data sources and inclusion criteria: To improve the search strategy coverage, we applied the search on PubMed and EMBASE. As the topic is also relevant to both public health, it was important to include CINAHL (The cumulative index for nursing and allied health services) as well (15–17).
Inclusion criteria: We included all observational, case-control, randomised controlled trials or review studies that measured ‘resilience’ as a dependent or independent variable in all healthcare system settings with no exclusion on participants or interventions basis.
Exclusion criteria: Studies or papers that did not include a discussion of resilience or did not examine the concept from a health system’s perspective were excluded. Examples of excluded articles are those focusing on the patient, personal resilience, etc.
To develop the most effective search strategy, we conducted a series of preliminary searches to explore the impact of alternative definitions on the number of articles identified. A search for MeSH terms "resilience" and “resilient” combined with "health system" was found to yield the highest number of records, therefore, we used this as a search strategy for all the databases used (Table 1). We carried out the last search on July, 1–2021, and created an alert on PubMed to capture any additional articles until December 30, 2021. We also searched the WHO websites and departments for additional literature.
Table 1
Search strategy for the concept analysis of health system resilience
Database | Search Results | Keyword |
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PubMed | 2587 | resilience: "resilience"[All Fields] OR "resiliences"[All Fields] OR "resiliencies"[All Fields] OR "resiliency"[All Fields] OR "resilient"[All Fields] OR "resilients"[All Fields] resilient: "resilience"[All Fields] OR "resiliences"[All Fields] OR "resiliencies"[All Fields] OR "resiliency"[All Fields] OR "resilient"[All Fields] OR "resilients"[All Fields] health systems: "Health Syst* OR ("health"[All Fields] AND "systems"[All Fields]) OR "health systems"[All Fields] |
PsycINFO | 149 | Health system and resilience |
CINAHL | 339 | Health system and resilience |
Ebscohost- Academic Search Premier | 250 | Health system and resilience |
Search engine for any type of paper published on health system resilience. The purpose is to identify work in the health system and system components with key words health system resilience.
Data extraction and coding: Following the Cochrane guidelines for systematic reviews, three researchers (DA, MZ, and CT) reviewed the abstracts. We eliminated all duplicates from our database and downloaded 2580 titles and abstracts on COVIDENCE program for systematic reviews management (18). Two reviewers screened each abstract using COVIDENCE program and disagreements were resolved by discussion with the third reviewer. Full-text articles of eligible titles were retrieved and screened for eligibility using the same methodology (19).
After agreeing on the manuscripts, each of the three reviewers examined the publications for definitions, attributes, antecedents, and consequences using a data extraction form (Annex 1). Attributes are the components, or characteristics of a concept. Antecedents are events or phenomena leading to resilience. Consequences or the results of the concept are the events that occur following the concept realisation. A list of attributes, antecedents, and consequences from the three researchers were compared, and a unified list was produced through consensus (9). Simultaneously we screened the articles reviewed for definitions, frameworks, and tools.